Provider Demographics
NPI:1477612406
Name:KAYALI, MOHAMED IHSAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MOHAMED
Middle Name:IHSAN
Last Name:KAYALI
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 1:1111 W COVINA BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3205
Mailing Address - Country:US
Mailing Address - Phone:909-599-9510
Mailing Address - Fax:909-599-1610
Practice Address - Street 1:1111 W COVINA BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3205
Practice Address - Country:US
Practice Address - Phone:909-599-9510
Practice Address - Fax:909-599-1610
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA444951223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics