MEDICARE: DIAA GHABBOUR

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	DN15155	FL

General Provider Information

NPI Number	:	1962504209
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIAA GHABBOUR

Provider Business Mailing Address
First Line	:	2502 N ROCKY POINT DR
Second Line	:	SUITE 1000-CREDENTIALING
City	:	TAMPA
State	:	FL
Zip	:	33607-1421
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5348 COUNTY ROAD 581
Second Line	:
City	:	WESLEY CHAPEL
State	:	FL
Zip	:	33543
Country	:	US
Telephone Number	:	813-973-1837
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2006
Last Update Date	:	07/08/2007

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