Provider Demographics
NPI:1801948435
Name:AL KHOURI, BASHAR
Entity type:Individual
Prefix:
First Name:BASHAR
Middle Name:
Last Name:AL KHOURI
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 1:121 W WINDHORST RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510-2434
Mailing Address - Country:US
Mailing Address - Phone:813-681-8151
Mailing Address - Fax:813-643-7977
Practice Address - Street 1:121 W WINDHORST RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-2434
Practice Address - Country:US
Practice Address - Phone:813-681-8151
Practice Address - Fax:813-643-7977
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13257122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist