MEDICARE: ENAS TAYYEM DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DDS105683	CA

General Provider Information

NPI Number	:	1134729601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ENAS TAYYEM DMD

Provider Business Mailing Address
First Line	:	2100 N BEACHWOOD DR APT 303
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90068-3442
Country	:	US
Telephone Number	:	435-294-6620
Fax Number	:

Provider Business Practice Location Address
First Line	:	2100 N BEACHWOOD DR APT 303
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90068-3442
Country	:	US
Telephone Number	:	435-294-6620
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2020
Last Update Date	:	10/26/2020

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