Provider Demographics
NPI:1699487017
Name:SULIOA KHOSHNAW, FADI QAYSSAR (DND)
Entity type:Individual
Prefix:
First Name:FADI QAYSSAR
Middle Name:
Last Name:SULIOA KHOSHNAW
Suffix:
Gender:M
Credentials:DND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 W LINCOLN AVE UNIT 272
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-5570
Mailing Address - Country:US
Mailing Address - Phone:559-283-2925
Mailing Address - Fax:
Practice Address - Street 1:11635 SOUTH ST
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:CA
Practice Address - Zip Code:90701-6628
Practice Address - Country:US
Practice Address - Phone:562-924-4401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-16
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1116361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program