=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942927629
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAHAWNEH DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2022
-----------------------------------------------------
Last Update Date | 10/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3635 E 1ST ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90063-2345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-269-7367
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 SPECTRUM CENTER DR STE 100
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-4963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-578-6358
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SHOROUQ SAMEER SAHAWNEH
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 714-578-6358
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------