Provider Demographics
NPI:1376957605
Name:GHANDOURAH, EZDEHAR (PDS, MCS, FACP)
Entity Type:Individual
Prefix:DR
First Name:EZDEHAR
Middle Name:
Last Name:GHANDOURAH
Suffix:
Gender:F
Credentials:PDS, MCS, FACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O.BOX 93098
Mailing Address - Street 2:
Mailing Address - City:RIYADH
Mailing Address - State:CENTRAL REGION
Mailing Address - Zip Code:11673
Mailing Address - Country:SA
Mailing Address - Phone:0096650-000-3705
Mailing Address - Fax:
Practice Address - Street 1:AL IMAM TURKI IBN ABDULLAH IBN MUHAMMAD, ULAISHAH
Practice Address - Street 2:
Practice Address - City:RIYADH
Practice Address - State:CENTRAL REGION
Practice Address - Zip Code:12746
Practice Address - Country:SA
Practice Address - Phone:0096611-435-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-14
Last Update Date:2014-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ06-R-D-233381223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics