Healthcare Provider Details

I. General information

NPI: 1194445155
Provider Name (Legal Business Name): WATHIQ KHAMIS DDS DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40625 ROAD 128
CUTLER CA
93615-2003
US

IV. Provider business mailing address

2839 ISABEL AVE
CLOVIS CA
93611-6085
US

V. Phone/Fax

Practice location:
  • Phone: 559-596-9231
  • Fax:
Mailing address:
  • Phone: 831-905-9070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: WATHIQ KHAMIS
Title or Position: OWNER
Credential: DDS
Phone: 831-905-9070