Provider Demographics
NPI:1437174398
Name:ENNABI, HAITHAM (DDS)
Entity Type:Individual
Prefix:
First Name:HAITHAM
Middle Name:
Last Name:ENNABI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:942 ROUTE 376
Mailing Address - Street 2:SUITE #13 SUMMERLIN PLAZA
Mailing Address - City:WAPPINGERS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12590-6483
Mailing Address - Country:US
Mailing Address - Phone:845-227-1996
Mailing Address - Fax:845-226-2865
Practice Address - Street 1:942 ROUTE 376
Practice Address - Street 2:SUITE #13 SUMMERLIN PLAZA
Practice Address - City:WAPPINGERS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12590-6483
Practice Address - Country:US
Practice Address - Phone:845-227-1996
Practice Address - Fax:845-226-2865
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049866122300000X, 1223G0001X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223G0001XDental ProvidersDentistGeneral Practice
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02254942Medicaid