Provider Demographics
NPI:1558812420
Name:AL KHATEEB D.D.S DENTAL CORPORATION
Entity Type:Organization
Organization Name:AL KHATEEB D.D.S DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HISHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ALKHATHEEB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-000-0000
Mailing Address - Street 1:267 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-3831
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:267 E 17TH ST
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3831
Practice Address - Country:US
Practice Address - Phone:714-000-0000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-17
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA416991223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty