MEDICARE: RISE DENTAL

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

General Provider Information

NPI Number	:	1790493252
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RISE DENTAL

Provider Business Mailing Address
First Line	:	255 SHADOW MOUNTAIN DR STE G&H
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-4757
Country	:	US
Telephone Number	:	915-831-9656
Fax Number	:

Provider Business Practice Location Address
First Line	:	255 SHADOW MOUNTAIN DR STE G&H
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-4757
Country	:	US
Telephone Number	:	915-831-9656
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. NASIM SALLOUM
Credential	:	DDS
Telephone Number	:	915-831-9656

Provider Enumeration Date	:	11/14/2022
Last Update Date	:	01/27/2023

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Directions to “RISE DENTAL ” Practice Location

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