MEDICARE: IBRAHIM MOHMAD AL-QAWAQNEH DDS

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	1223G0001X	General Practice Dentistry	46726	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G9276201	OTHER	CA	DENTI-CAL NUMBER

General Provider Information

NPI Number	:	1194805887
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IBRAHIM MOHMAD AL-QAWAQNEH DDS

Provider Business Mailing Address
First Line	:	1719 W ROMNEYA DR
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92801-1804
Country	:	US
Telephone Number	:	714-991-3900
Fax Number	:	714-991-3999

Provider Business Practice Location Address
First Line	:	1719 W ROMNEYA DR
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92801-1804
Country	:	US
Telephone Number	:	714-991-3900
Fax Number	:	714-991-3999

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

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	07/08/2007

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