Healthcare Provider Details

I. General information

NPI: 1891917860
Provider Name (Legal Business Name): MEDHAT M.RAOUF ROFAEL D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 12/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17150 EUCLID ST. SUITE 322
FOUNTAIN VALLEY CA
92708
US

IV. Provider business mailing address

17150 EUCLID ST. SUITE 322
FOUNTAIN VALLEY CA
92708
US

V. Phone/Fax

Practice location:
  • Phone: 714-444-4224
  • Fax: 714-444-9480
Mailing address:
  • Phone: 714-444-4224
  • Fax: 714-444-9480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number40714
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: