=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003369075
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMI SHAHHAL D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2016
-----------------------------------------------------
Last Update Date | 07/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 740 NORDAHL RD STE 121
-----------------------------------------------------
City | SAN MARCOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92069-3545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-746-7008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 740 NORDAHL RD STE 121
-----------------------------------------------------
City | SAN MARCOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92069-3545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-746-7008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 100547
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------