Provider Demographics
NPI:1518214113
Name:FAWAZ, KHALED SUDKI (DDS)
Entity Type:Individual
Prefix:DR
First Name:KHALED
Middle Name:SUDKI
Last Name:FAWAZ
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 1:26902 OSO PKWY STE 190
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-5808
Mailing Address - Country:US
Mailing Address - Phone:949-582-9206
Mailing Address - Fax:
Practice Address - Street 1:26902 OSO PKWY
Practice Address - Street 2:SUITE 190
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-5801
Practice Address - Country:US
Practice Address - Phone:949-582-9206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40586122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist