Healthcare Provider Details

I. General information

NPI: 1235271917
Provider Name (Legal Business Name): BASHAR DALLOUL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8997 MIRA MESA BLVD
SAN DIEGO CA
92126-2738
US

IV. Provider business mailing address

6465 BALBOA AVE SUITE B
SAN DIEGO CA
92111-3155
US

V. Phone/Fax

Practice location:
  • Phone: 858-536-5550
  • Fax:
Mailing address:
  • Phone: 858-349-9201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number53445
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: