Provider Demographics
NPI:1891987384
Name:GHANDOUR, DIMA (DMD)
Entity Type:Individual
Prefix:
First Name:DIMA
Middle Name:
Last Name:GHANDOUR
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1454 MADISON AVE W
Mailing Address - Street 2:
Mailing Address - City:IMMOKALEE
Mailing Address - State:FL
Mailing Address - Zip Code:34142-2200
Mailing Address - Country:US
Mailing Address - Phone:239-658-3721
Mailing Address - Fax:239-263-1932
Practice Address - Street 1:4077 TAMIAMI TRL N
Practice Address - Street 2:SUITE D203
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-8737
Practice Address - Country:US
Practice Address - Phone:239-658-3721
Practice Address - Fax:239-263-1932
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-17
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18045122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017212900Medicaid