Provider Demographics
NPI:1053450577
Name:AYOUB, WISSAM (DDS)
Entity Type:Individual
Prefix:
First Name:WISSAM
Middle Name:
Last Name:AYOUB
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18800 MAIN ST STE 203
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-1718
Mailing Address - Country:US
Mailing Address - Phone:714-848-2277
Mailing Address - Fax:
Practice Address - Street 1:18800 MAIN ST STE 203
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-1718
Practice Address - Country:US
Practice Address - Phone:714-848-2277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD70791223G0001X
CA554961223G0001X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice