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	:	1740665504
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAHAWNEH DENTAL CORPORATION

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

Provider Business Practice Location Address
First Line	:	17003 BEAR VALLEY RD
Second Line	:	SUITE D
City	:	HESPERIA
State	:	CA
Zip	:	92345-1419
Country	:	US
Telephone Number	:	760-244-1900
Fax Number	:	760-244-4151

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

Provider Enumeration Date	:	07/22/2015
Last Update Date	:	07/22/2015

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