Healthcare Provider Details

I. General information

NPI: 1740804228
Provider Name (Legal Business Name): AHMAD MATIN RASUL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2020
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 W HOSPITALITY LN STE 201
SAN BERNARDINO CA
92408-3348
US

IV. Provider business mailing address

159 W HOSPITALITY LN STE 201
SAN BERNARDINO CA
92408-3348
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-4960
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number102762
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number102762
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: