=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881290112
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AHMAD MERSAL DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2020
-----------------------------------------------------
Last Update Date | 01/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 652 E REGENT ST
-----------------------------------------------------
City | INGLEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90301-1415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-330-0604
-----------------------------------------------------
Fax | 310-330-0590
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2008 GRAHAM AVE
-----------------------------------------------------
City | REDONDO BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90278-1923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-658-1636
-----------------------------------------------------
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 | 105863
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------