Provider Demographics
NPI:1801060736
Name:EBRAHIM, HOSSEIN K (DMD)
Entity type:Individual
Prefix:DR
First Name:HOSSEIN
Middle Name:K
Last Name:EBRAHIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:KIA
Other - Middle Name:
Other - Last Name:EBRAHIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:32515 GOLDEN LANTERN ST STE D
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-3259
Mailing Address - Country:US
Mailing Address - Phone:800-661-0816
Mailing Address - Fax:800-661-0816
Practice Address - Street 1:32515 GOLDEN LANTERN ST STE D
Practice Address - Street 2:
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-3259
Practice Address - Country:US
Practice Address - Phone:800-661-0816
Practice Address - Fax:800-661-0816
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice