=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992464655
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ASMAHAN IBRAHEEM MIKHA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2021
-----------------------------------------------------
Last Update Date | 12/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2654 JAMACHA RD STE 113
-----------------------------------------------------
City | EL CAJON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92019-4327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-303-0930
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1155 TUCSON CT
-----------------------------------------------------
City | EL CAJON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92021-5123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-658-8222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 107175
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------