Healthcare Provider Details

I. General information

NPI: 1700537446
Provider Name (Legal Business Name): HAITHAM M HAITHAM OTHMAN AGHA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2022
Last Update Date: 01/14/2022
Certification Date: 01/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 W STASSNEY LN
AUSTIN TX
78745-3178
US

IV. Provider business mailing address

4095 COUNTRYDOWN DR
GREENVILLE NC
27834-0546
US

V. Phone/Fax

Practice location:
  • Phone: 929-389-2343
  • Fax:
Mailing address:
  • Phone: 929-389-2343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number31626
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: