Healthcare Provider Details

I. General information

NPI: 1114041456
Provider Name (Legal Business Name): DR. LOUIE HAIDAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 12/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12649 POWAY RD
POWAY CA
92064-4415
US

IV. Provider business mailing address

8076 DICENZA LN
SAN DIEGO CA
92119-1124
US

V. Phone/Fax

Practice location:
  • Phone: 858-486-6100
  • Fax: 858-486-4564
Mailing address:
  • Phone: 858-335-9390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number51780
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: