1346365657 NPI number — SOPHIA ROZOV DDS, INC

Table of content: (NPI 1346365657)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346365657 NPI number — SOPHIA ROZOV DDS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOPHIA ROZOV DDS, INC
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:
SMILE AVENUE DENTAL GROUP
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:
1346365657
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5640 ETIWANDA AVE
Provider Second Line Business Mailing Address:
# 5
Provider Business Mailing Address City Name:
TARZANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91356-2700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-904-0400
Provider Business Mailing Address Fax Number:
562-904-1803

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8543 ROSEMEAD BLVD
Provider Second Line Business Practice Location Address:
# D
Provider Business Practice Location Address City Name:
PICO RIVERA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90660-5427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-904-0400
Provider Business Practice Location Address Fax Number:
562-904-1803
Provider Enumeration Date:
03/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROZOV
Authorized Official First Name:
SOPHIA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
562-904-0400

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  45820 , 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)

  • Identifier: 01-45820 . This is a "DELTA-DENTAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: G93356-01 . This is a "DENTI-CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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