Provider Demographics
NPI:1487703500
Name:DIMACHKI, TALAL
Entity type:Individual
Prefix:DR
First Name:TALAL
Middle Name:
Last Name:DIMACHKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 SPECTRUM
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3135
Mailing Address - Country:US
Mailing Address - Phone:315-278-2763
Mailing Address - Fax:
Practice Address - Street 1:2120 SPECTRUM
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618
Practice Address - Country:US
Practice Address - Phone:315-278-2763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000009122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02510507Medicaid