Healthcare Provider Details

I. General information

NPI: 1649000423
Provider Name (Legal Business Name): AHMAD HIKMAT ABOUDAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2024
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2706 RYAN ST
LAKE CHARLES LA
70601-7328
US

IV. Provider business mailing address

4000 DUNWOODY PARK APT 2310
ATLANTA GA
30338-7957
US

V. Phone/Fax

Practice location:
  • Phone: 337-944-0300
  • Fax:
Mailing address:
  • Phone: 312-890-8004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number40947
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number7619
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: