1073737524 NPI number — PAKRAVAN DENTAL CORPORATION

Table of content: (NPI 1073737524)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073737524 NPI number — PAKRAVAN DENTAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAKRAVAN DENTAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WEST COAST DENTAL GROUP OF ORANGE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073737524
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
179 N TUSTIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92867-7716
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-288-1035
Provider Business Mailing Address Fax Number:
714-288-2784

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
179 N TUSTIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92867-7716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-288-1035
Provider Business Practice Location Address Fax Number:
714-288-2784
Provider Enumeration Date:
04/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PAKRAVAN
Authorized Official First Name:
FARID
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
714-288-1035

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  39862 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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