Healthcare Provider Details

I. General information

NPI: 1306392501
Provider Name (Legal Business Name): CHADI BACHOUR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 COVINGTON ST
YOUNGSTOWN OH
44510-1617
US

IV. Provider business mailing address

1001 COVINGTON
YOUNGSTOWN OH
44504
US

V. Phone/Fax

Practice location:
  • Phone: 724-877-9120
  • Fax:
Mailing address:
  • Phone: 724-877-9120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30.025604
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: