Healthcare Provider Details

I. General information

NPI: 1063773661
Provider Name (Legal Business Name): SAHAWNEH DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2012
Last Update Date: 07/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3358 S BRISTOL ST
SANTA ANA CA
92705
US

IV. Provider business mailing address

3358 S BRISTOL ST
SANTA ANA CA
92705
US

V. Phone/Fax

Practice location:
  • Phone: 714-361-2141
  • Fax: 714-979-1659
Mailing address:
  • Phone: 714-361-2141
  • Fax: 714-979-1659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number55643
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. SHOROUQ SAHAWNEH
Title or Position: PRESIDENT
Credential: DDS
Phone: 714-578-6358