Provider Demographics
NPI:1831269489
Name:FAYOUMI, HASSAN M (DDS)
Entity type:Individual
Prefix:
First Name:HASSAN
Middle Name:M
Last Name:FAYOUMI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 N JUANITA AVE
Mailing Address - Street 2:#3
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277
Mailing Address - Country:US
Mailing Address - Phone:310-699-1549
Mailing Address - Fax:
Practice Address - Street 1:8615 S BROADWAY
Practice Address - Street 2:KLEINMAN & WALLACE PROF DENTAL CORP
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003
Practice Address - Country:US
Practice Address - Phone:323-752-3116
Practice Address - Fax:323-752-7203
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA526041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice