Provider Demographics
NPI:1730696519
Name:BARSOUM DENTAL CORP
Entity type:Organization
Organization Name:BARSOUM DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAHER
Authorized Official - Middle Name:LABIB
Authorized Official - Last Name:BARSOUM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-902-1708
Mailing Address - Street 1:14613 RAMONA AVE
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710
Mailing Address - Country:US
Mailing Address - Phone:909-902-1708
Mailing Address - Fax:909-902-1709
Practice Address - Street 1:14613 RAMONA AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710
Practice Address - Country:US
Practice Address - Phone:909-902-1708
Practice Address - Fax:909-902-1709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA572311223E0200X
CA642291223P0300X
CA641081223S0112X
CA610001223X0400X
CA441451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty