Healthcare Provider Details

I. General information

NPI: 1861701971
Provider Name (Legal Business Name): MAHER AL-BOUZ DENTAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2010
Last Update Date: 10/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

639 E. FOOTHILL BLVD SUITE A
SAN DIMAS CA
91773
US

IV. Provider business mailing address

639 E. FOOTHILL BLVD SUITE A
SAN DIMAS CA
91773
US

V. Phone/Fax

Practice location:
  • Phone: 909-599-2029
  • Fax: 909-599-4342
Mailing address:
  • Phone: 909-599-2029
  • Fax: 909-599-4342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number46013
License Number StateCA

VIII. Authorized Official

Name: MAHER AL-BOUZ
Title or Position: OWNER
Credential: DDS
Phone: 909-599-2029