Provider Demographics
NPI:1477518819
Name:HAMMOUDEH, BASIL (DMD)
Entity Type:Individual
Prefix:
First Name:BASIL
Middle Name:
Last Name:HAMMOUDEH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6452 VINELAND RD UNIT 301
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-7875
Mailing Address - Country:US
Mailing Address - Phone:407-929-9495
Mailing Address - Fax:
Practice Address - Street 1:4307 E COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-5217
Practice Address - Country:US
Practice Address - Phone:407-514-0400
Practice Address - Fax:407-206-3573
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL174611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001974700Medicaid