Provider Demographics
NPI:1912533597
Name:AL SAMMARRAIE, MOHLAB (DDS)
Entity type:Individual
Prefix:
First Name:MOHLAB
Middle Name:
Last Name:AL SAMMARRAIE
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 1:10418 VALLEY BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91731-3600
Mailing Address - Country:US
Mailing Address - Phone:619-548-0856
Mailing Address - Fax:
Practice Address - Street 1:10418 VALLEY BLVD STE B
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-3600
Practice Address - Country:US
Practice Address - Phone:619-548-0856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-16
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1048311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA104831OtherDENTAL BOARD OF CALIFORNIA