Provider Demographics
NPI:1740473412
Name:FAWAZ, RAED S (BS DDS)
Entity type:Individual
Prefix:DR
First Name:RAED
Middle Name:S
Last Name:FAWAZ
Suffix:
Gender:M
Credentials:BS DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26902 OSO PKWY
Mailing Address - Street 2:190
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-5801
Mailing Address - Country:US
Mailing Address - Phone:949-582-9206
Mailing Address - Fax:
Practice Address - Street 1:26902 OSO PKWY
Practice Address - Street 2:190
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-5801
Practice Address - Country:US
Practice Address - Phone:949-582-9206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA421491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice