Provider Demographics
NPI:1144302001
Name:ANTAKI, GHASSAN R (DDS)
Entity type:Individual
Prefix:DR
First Name:GHASSAN
Middle Name:R
Last Name:ANTAKI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:GHASSAN
Other - Middle Name:R
Other - Last Name:ANTAKI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:961 APPALACHIAN
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-8307
Mailing Address - Country:US
Mailing Address - Phone:909-625-2568
Mailing Address - Fax:
Practice Address - Street 1:961 APPALACHIAN
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-8307
Practice Address - Country:US
Practice Address - Phone:909-625-2568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA380241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice