Provider Demographics
NPI:1760842066
Name:AL JAWHAR, QUSSAY
Entity Type:Individual
Prefix:
First Name:QUSSAY
Middle Name:
Last Name:AL JAWHAR
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 1:3011 HIGHWAY 30 W STE 101C
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77340-3534
Mailing Address - Country:US
Mailing Address - Phone:936-294-0400
Mailing Address - Fax:936-294-0403
Practice Address - Street 1:3011 HIGHWAY 30 W STE 101C
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340-3534
Practice Address - Country:US
Practice Address - Phone:936-294-0400
Practice Address - Fax:936-294-0403
Is Sole Proprietor?:No
Enumeration Date:2016-02-29
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX316771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice