Provider Demographics
NPI:1407903776
Name:EISSA, KHALED (BDS)
Entity Type:Individual
Prefix:
First Name:KHALED
Middle Name:
Last Name:EISSA
Suffix:
Gender:M
Credentials:BDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1935 DAINTY WAY
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92545-8960
Mailing Address - Country:US
Mailing Address - Phone:763-587-8345
Mailing Address - Fax:
Practice Address - Street 1:1935 DAINTY WAY
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-8960
Practice Address - Country:US
Practice Address - Phone:763-587-8345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12352122300000X
CA59237122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist