Provider Demographics
NPI:1801952239
Name:KHOURY, ISAM HANNA (DMD)
Entity type:Individual
Prefix:DR
First Name:ISAM
Middle Name:HANNA
Last Name:KHOURY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 SOUTHGATE AVE
Mailing Address - Street 2:#103
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-2259
Mailing Address - Country:US
Mailing Address - Phone:650-991-0999
Mailing Address - Fax:650-991-0918
Practice Address - Street 1:1500 SOUTHGATE AVE
Practice Address - Street 2:#103
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2259
Practice Address - Country:US
Practice Address - Phone:650-991-0999
Practice Address - Fax:650-991-0918
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADP0359221223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB35922-01Medicaid
CAB35922-01Medicaid