Basic Information
Provider Information | |||||||||
NPI: | 1982739736 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILLIAM | ||||||||
FirstName: | SALLY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HABIB | ||||||||
OtherFirstName: | SALLY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DDS | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 659 S CENTRAL VALLEY HWY | ||||||||
Address2: | P.O. BOX 1060 | ||||||||
City: | SHAFTER | ||||||||
State: | CA | ||||||||
PostalCode: | 932632790 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6614591900 | ||||||||
FaxNumber: | 6614591974 | ||||||||
Practice Location | |||||||||
Address1: | 525 ROBERTS LANE | ||||||||
Address2: |   | ||||||||
City: | OILDALE | ||||||||
State: | CA | ||||||||
PostalCode: | 933080000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6613927850 | ||||||||
FaxNumber: | 6612152349 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/22/2007 | ||||||||
LastUpdateDate: | 01/24/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 55404 | CA | Y |   | Dental Providers | Dentist |   |
No ID Information.