Provider Demographics
NPI:1952745895
Name:KHALED EISSA DDS INC
Entity Type:Organization
Organization Name:KHALED EISSA DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:DR
Authorized Official - First Name:KHALED
Authorized Official - Middle Name:
Authorized Official - Last Name:EISSA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-587-8345
Mailing Address - Street 1:1935 DAINTY WAY
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92545-8960
Mailing Address - Country:US
Mailing Address - Phone:763-587-8345
Mailing Address - Fax:
Practice Address - Street 1:31737 RIVERSIDE DR STE B
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-7890
Practice Address - Country:US
Practice Address - Phone:951-674-8707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-22
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59237122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty