Provider Demographics
NPI:1235315433
Name:HETATA & ALKHATEEB DENTAL CORP
Entity Type:Organization
Organization Name:HETATA & ALKHATEEB DENTAL CORP
Other - Org Name:MESA DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MAHA
Authorized Official - Middle Name:I
Authorized Official - Last Name:HETATA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-646-2411
Mailing Address - Street 1:267 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627
Mailing Address - Country:US
Mailing Address - Phone:949-646-2411
Mailing Address - Fax:949-646-9141
Practice Address - Street 1:267 E 17TH ST
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627
Practice Address - Country:US
Practice Address - Phone:949-646-2411
Practice Address - Fax:949-646-9141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-17
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40830122300000X
CA41699122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty