Provider Demographics
NPI:1356864870
Name:ABDALLAH, EMAD
Entity Type:Individual
Prefix:
First Name:EMAD
Middle Name:
Last Name:ABDALLAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1347 BURNING ARROW
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-2765
Mailing Address - Country:US
Mailing Address - Phone:617-319-1050
Mailing Address - Fax:
Practice Address - Street 1:2311 HARRY WURZBACH RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-5543
Practice Address - Country:US
Practice Address - Phone:210-824-3531
Practice Address - Fax:210-824-0068
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-18
Last Update Date:2023-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901022392122300000X
TX38276122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty