Provider Demographics
NPI: | 1134316052 |
---|---|
Name: | AWNIE A AMMAR, DDS, PROFESSIONAL DENTAL CORPORATION |
Entity Type: | Organization |
Organization Name: | AWNIE A AMMAR, DDS, PROFESSIONAL DENTAL CORPORATION |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | AWNIE |
Authorized Official - Middle Name: | A |
Authorized Official - Last Name: | AMMAR |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DDS |
Authorized Official - Phone: | 209-239-7779 |
Mailing Address - Street 1: | 1104 N MAIN ST |
Mailing Address - Street 2: | |
Mailing Address - City: | MANTECA |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 95336-3208 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 209-239-7779 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1104 N MAIN ST |
Practice Address - Street 2: | |
Practice Address - City: | MANTECA |
Practice Address - State: | CA |
Practice Address - Zip Code: | 95336-3208 |
Practice Address - Country: | US |
Practice Address - Phone: | 209-239-7779 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-09-25 |
Last Update Date: | 2007-09-25 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | 42094 | 261QD0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QD0000X | Ambulatory Health Care Facilities | Clinic/Center | Dental |