1528831781 NPI number — SOROURS DENTAL OFFICE CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528831781 NPI number — SOROURS DENTAL OFFICE CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOROURS DENTAL OFFICE 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:
Provider Other Organization Name Type Code:
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:
1528831781
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6633 ATLANTIC AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90201-2523
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-456-7377
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17185 ARROW BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FONTANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92335-3972
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-587-2474
Provider Business Practice Location Address Fax Number:
909-365-4358
Provider Enumeration Date:
10/31/2023

Additional Information

Authorized Official

Authorized Official Last Name:
SOROUR
Authorized Official First Name:
SELVANA
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
310-795-3363

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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