MEDICARE: MOHAMED KAYS DOWAIDARI DDS PC DELICATE DENTAL SPA DENTAL GROUP

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	53592	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508376989
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOHAMED KAYS DOWAIDARI DDS PC DELICATE DENTAL SPA DENTAL GROUP

Provider Business Mailing Address
First Line	:	1635 N MOUNTAIN AVE
Second Line	:
City	:	UPLAND
State	:	CA
Zip	:	91784-1732
Country	:	US
Telephone Number	:	909-982-3300
Fax Number	:	909-982-3350

Provider Business Practice Location Address
First Line	:	1635 N MOUNTAIN AVE
Second Line	:
City	:	UPLAND
State	:	CA
Zip	:	91784-1732
Country	:	US
Telephone Number	:	909-982-3300
Fax Number	:	909-982-3350

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	NATASHA L CHATMAN
Credential	:
Telephone Number	:	909-982-3300

Provider Enumeration Date	:	10/11/2017
Last Update Date	:	09/26/2018

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