Provider Demographics
NPI:1497365662
Name:SALLOUM, NASIM
Entity Type:Individual
Prefix:
First Name:NASIM
Middle Name:
Last Name:SALLOUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7598 N MESA ST STE A
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-3518
Mailing Address - Country:US
Mailing Address - Phone:915-831-9656
Mailing Address - Fax:
Practice Address - Street 1:7598 N MESA ST STE A
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-3518
Practice Address - Country:US
Practice Address - Phone:915-831-9656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-03
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD53061223G0001X
TX364791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice