Healthcare Provider Details

I. General information

NPI: 1588236236
Provider Name (Legal Business Name): JEANINE CHAFIK FARID KHOURY DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2021
Last Update Date: 07/13/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 N ORANGE ST UNIT 216
GLENDALE CA
91203-5503
US

IV. Provider business mailing address

321 N ORANGE ST UNIT 216
GLENDALE CA
91203-5503
US

V. Phone/Fax

Practice location:
  • Phone: 818-512-8142
  • Fax:
Mailing address:
  • Phone: 818-512-8142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number106480
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: