Healthcare Provider Details

I. General information

NPI: 1043211873
Provider Name (Legal Business Name): ABDALLAH AL-HARAZNEH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 04/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1038 W MAIN ST
SANTA MARIA CA
93458-4238
US

IV. Provider business mailing address

1038 W MAIN ST
SANTA MARIA CA
93458-4238
US

V. Phone/Fax

Practice location:
  • Phone: 805-925-9091
  • Fax: 805-925-9022
Mailing address:
  • Phone: 805-925-9091
  • Fax: 805-925-9022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number46725
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: