Provider Demographics
NPI:1235113598
Name:GHANNOUM, SAMMY (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAMMY
Middle Name:
Last Name:GHANNOUM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 BAY RIDGE PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-3310
Mailing Address - Country:US
Mailing Address - Phone:718-491-5666
Mailing Address - Fax:
Practice Address - Street 1:522 BAY RIDGE PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-3310
Practice Address - Country:US
Practice Address - Phone:718-491-5666
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-30
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0472951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice