Provider Demographics
NPI:1467857391
Name:MONA A FAHMY D.D.S. INC.
Entity Type:Organization
Organization Name:MONA A FAHMY D.D.S. INC.
Other - Org Name:BUENA PARK DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MONA
Authorized Official - Middle Name:ADEL
Authorized Official - Last Name:FAHMY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-739-2051
Mailing Address - Street 1:8402 COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-2528
Mailing Address - Country:US
Mailing Address - Phone:714-739-2051
Mailing Address - Fax:714-739-5146
Practice Address - Street 1:8402 COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-2528
Practice Address - Country:US
Practice Address - Phone:714-739-2051
Practice Address - Fax:714-739-5146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA393581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB39358-01OtherDENTI-CAL (MEDI-CAL)