Provider Demographics
NPI:1134316052
Name:AWNIE A AMMAR, DDS, PROFESSIONAL DENTAL CORPORATION
Entity type:Organization
Organization Name:AWNIE A AMMAR, DDS, PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AWNIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:AMMAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:209-239-7779
Mailing Address - Street 1:1104 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-3208
Mailing Address - Country:US
Mailing Address - Phone:209-239-7779
Mailing Address - Fax:
Practice Address - Street 1:1104 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-3208
Practice Address - Country:US
Practice Address - Phone:209-239-7779
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42094261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental