Saied Samuel Ahdout, DMD
Individual provider Active NPI Periodontics · Wildomar, CA
NPI 1215032115 · NPPES record last updated Jul 8, 2007
Key facts
- NPI
- 1215032115
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Periodontics 1223P0300X
- License
- 37772 (CA)
- Practice address
- 23905 Clinton Keith Rd
Ste. 108
Wildomar, CA 92595-7897 - Phone
- (951) 304-9700
- Fax
- (951) 304-9711
- NPI assigned
- Sep 14, 2006
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in CA
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20150706000221 | CA | Order and Referring Only - Dentist |
4981916962 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 37772 | CA | MD | Marriage & Family Therapist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Diana DO-Yabut and Bryan Watanabe Dental Corporation | Periodontics | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Periodontics | 1223P0300X | 37772 | CA | Yes |
Addresses
Primary practice location
23905 Clinton Keith Rd
Ste. 108
Wildomar, CA 92595-7897
Mailing address
2860 Michelle
2ND Floor
Irvine, CA 92606-1009
Phone (714) 508-3600
Other providers in Wildomar, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 8, 2007. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.