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General NPI Number Information
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NPI Number | 1699200220
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Entity Type | Organization
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Legal Business Name | FARWEST DENTAL GROUP
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Dates
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Enumeration Date | 04/20/2017
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Last Update Date | 04/20/2017
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Provider Practice Location Address
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Address Line | 1704 N AVALON BLVD
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City | WILMINGTON
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State | CA
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Zip | 90744-1433
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Country | US
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Telephone | 310-835-5130
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Fax | 310-835-6090
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Provider Business Mailing Address
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Address Line | 1704 N AVALON BLVD
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City | WILMINGTON
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State | CA
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Zip | 90744-1433
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Country | US
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Telephone | 310-835-5130
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Fax | 310-835-6090
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Authorized Official
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Title or Position | ONWER
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Name | DR. HASSAN FAYOUMI
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Credential | DDS
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Telephone | 310-699-1549
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 52604
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License Number State | CA
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