Provider Demographics
NPI:1699079418
Name:KHAMIS, WATHIQ ISMAIL (DDS)
Entity type:Individual
Prefix:DR
First Name:WATHIQ
Middle Name:ISMAIL
Last Name:KHAMIS
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 1:493 LAVELL CT
Mailing Address - Street 2:
Mailing Address - City:MARINA
Mailing Address - State:CA
Mailing Address - Zip Code:93933-3410
Mailing Address - Country:US
Mailing Address - Phone:831-905-9070
Mailing Address - Fax:
Practice Address - Street 1:808 OAK AVE
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:CA
Practice Address - Zip Code:93927-5648
Practice Address - Country:US
Practice Address - Phone:831-674-5344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-08
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA601071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice