Healthcare Provider Details

I. General information

NPI: 1023609948
Provider Name (Legal Business Name): FAHAD LAITH UKAILY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: FAHAD LAITH MOHAMMED MOHAMMED

II. Dates (important events)

Enumeration Date: 02/02/2021
Last Update Date: 07/24/2023
Certification Date: 07/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1539 E PLAZA BLVD
NATIONAL CITY CA
91950-3641
US

IV. Provider business mailing address

10800 DEWITT CT
EL CAJON CA
92020-8113
US

V. Phone/Fax

Practice location:
  • Phone: 619-419-1248
  • Fax:
Mailing address:
  • Phone: 619-956-6519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number105988
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: