Provider Demographics
NPI:1124388913
Name:HOSSEIN K. EBRAHIM, D.M.D. INC,
Entity type:Organization
Organization Name:HOSSEIN K. EBRAHIM, D.M.D. INC,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HOSSEIN
Authorized Official - Middle Name:KIA
Authorized Official - Last Name:EBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:949-350-6350
Mailing Address - Street 1:32122 PASEO ADELANTO
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-3605
Mailing Address - Country:US
Mailing Address - Phone:949-493-6166
Mailing Address - Fax:949-493-8910
Practice Address - Street 1:32122 PASEO ADELANTO
Practice Address - Street 2:SUITE 1B
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-3605
Practice Address - Country:US
Practice Address - Phone:949-493-6166
Practice Address - Fax:949-493-8910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-25
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37778122300000X
CA36307122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty