Provider Demographics
NPI:1194445155
Name:WATHIQ KHAMIS DDS DENTAL CORPORATION
Entity type:Organization
Organization Name:WATHIQ KHAMIS DDS DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WATHIQ
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAMIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:831-905-9070
Mailing Address - Street 1:2839 ISABEL AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-6085
Mailing Address - Country:US
Mailing Address - Phone:831-905-9070
Mailing Address - Fax:
Practice Address - Street 1:40625 ROAD 128
Practice Address - Street 2:
Practice Address - City:CUTLER
Practice Address - State:CA
Practice Address - Zip Code:93615-2003
Practice Address - Country:US
Practice Address - Phone:559-596-9231
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty