Provider Demographics
NPI:1114017282
Name:HASSAN, HESHAM MAHMOUD (DDS)
Entity Type:Individual
Prefix:DR
First Name:HESHAM
Middle Name:MAHMOUD
Last Name:HASSAN
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 1:408 W GROVE ST
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-1634
Mailing Address - Country:US
Mailing Address - Phone:626-641-2862
Mailing Address - Fax:
Practice Address - Street 1:408 W GROVE ST
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1634
Practice Address - Country:US
Practice Address - Phone:626-641-2862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA512591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice