=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639417306
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAWZY TADROS DDS.INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2013
-----------------------------------------------------
Last Update Date | 01/30/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12601 SAN FERNANDO RD STE H
-----------------------------------------------------
City | SYLMAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91342-7733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-364-1991
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12601 SAN FERNANDO RD STE H
-----------------------------------------------------
City | SYLMAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91342-7733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | FAWZY TADROS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 818-364-1991
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 49677
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------