Provider Demographics
NPI:1033261391
Name:SAN DIMAS PERIODONTICS
Entity Type:Organization
Organization Name:SAN DIMAS PERIODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:IHSAN
Authorized Official - Last Name:KAYALI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-599-9510
Mailing Address - Street 1:1111 W COVINA BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3205
Mailing Address - Country:US
Mailing Address - Phone:909-599-9510
Mailing Address - Fax:909-599-1610
Practice Address - Street 1:1111 W COVINA BLVD STE 220
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3205
Practice Address - Country:US
Practice Address - Phone:909-599-9510
Practice Address - Fax:909-599-1610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA444951223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty