MEDICARE: SAHAWNEH DENTAL CORPORATION

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	55643	CA

General Provider Information

NPI Number	:	1427433069
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAHAWNEH DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	100 SPECTRUM CENTER DR
Second Line	:	STE 100
City	:	IRVINE
State	:	CA
Zip	:	92618-4962
Country	:	US
Telephone Number	:	714-578-6358
Fax Number	:	949-861-9868

Provider Business Practice Location Address
First Line	:	4550 W PICO BLVD
Second Line	:	SUITE C309
City	:	LOS ANGELES
State	:	CA
Zip	:	90019-4257
Country	:	US
Telephone Number	:	323-602-0590
Fax Number	:	323-933-3255

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. SHOROUQ SAHAWNEH
Credential	:	DDS
Telephone Number	:	714-578-6358

Provider Enumeration Date	:	07/24/2015
Last Update Date	:	07/24/2015

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