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
2	122300000X	Dentist

General Provider Information

NPI Number	:	1891190963
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAHAWNEH DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	18121 CHATSWORTH ST
Second Line	:
City	:	GRANADA HILLS
State	:	CA
Zip	:	91344-5610
Country	:	US
Telephone Number	:	818-491-0056
Fax Number	:	818-363-2867

Provider Business Practice Location Address
First Line	:	18121 CHATSWORTH ST
Second Line	:
City	:	GRANADA HILLS
State	:	CA
Zip	:	91344-5610
Country	:	US
Telephone Number	:	818-491-0056
Fax Number	:	818-363-2867

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

Provider Enumeration Date	:	10/30/2014
Last Update Date	:	07/24/2015

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