MEDICARE: HAITHAM ELGENDI DDS INC

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

General Provider Information

NPI Number	:	1942275128
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAITHAM ELGENDI DDS INC

Provider Business Mailing Address
First Line	:	824 S ALVARADO ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90057-4010
Country	:	US
Telephone Number	:	213-252-1700
Fax Number	:	213-252-8108

Provider Business Practice Location Address
First Line	:	824 S ALVARADO ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90057-4010
Country	:	US
Telephone Number	:	213-252-1700
Fax Number	:	213-252-8108

Authorized Official
Title or Position	:	OWNER
Name	:	HAITHAM H ELGENDI
Credential	:	DDS
Telephone Number	:	213-252-1700

Provider Enumeration Date	:	02/21/2006
Last Update Date	:	06/13/2008

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