Healthcare Provider Details

I. General information

NPI: 1396120937
Provider Name (Legal Business Name): SAHAWNEH DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2015
Last Update Date: 07/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

697 S GAFFEY ST
SAN PEDRO CA
90731-3026
US

IV. Provider business mailing address

100 SPECTRUM CENTER DR STE 100
IRVINE CA
92618-4962
US

V. Phone/Fax

Practice location:
  • Phone: 310-548-1273
  • Fax: 310-548-0753
Mailing address:
  • Phone: 714-578-6358
  • Fax: 949-861-9868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number55643
License Number StateCA

VIII. Authorized Official

Name: SHOROUQ SAHAWNEH
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 714-578-6358