Healthcare Provider Details

I. General information

NPI: 1962626861
Provider Name (Legal Business Name): EDDIE AL HALASA DDS,MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: ODAY HUSAM ALHALASA DDS,MSD

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71780 SAN JACINTO DR B3
RANCHO MIRAGE CA
92270-5516
US

IV. Provider business mailing address

71780 SAN JACINTO DR STE B3
RANCHO MIRAGE CA
92270-5517
US

V. Phone/Fax

Practice location:
  • Phone: 760-779-0350
  • Fax: 760-779-0348
Mailing address:
  • Phone: 760-779-0350
  • Fax: 760-779-0348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number50882
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: