Provider Demographics
NPI:1386139905
Name:HUSSEIN, TAREK (DDS)
Entity type:Individual
Prefix:
First Name:TAREK
Middle Name:
Last Name:HUSSEIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9925 DATE ST
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-6511
Mailing Address - Country:US
Mailing Address - Phone:424-255-2035
Mailing Address - Fax:
Practice Address - Street 1:78595 HIGHWAY 111 STE 300
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253
Practice Address - Country:US
Practice Address - Phone:760-771-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-26
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA102723122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program