Provider Demographics
NPI:1013577071
Name:EDALAT DDS INC.
Entity Type:Organization
Organization Name:EDALAT DDS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENDODONTIST-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HOSSEIN
Authorized Official - Middle Name:
Authorized Official - Last Name:EDALAT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-999-8777
Mailing Address - Street 1:18625 BROOKHURST ST
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-6748
Mailing Address - Country:US
Mailing Address - Phone:949-409-4080
Mailing Address - Fax:949-284-9200
Practice Address - Street 1:130 AVENIDA CABRILLO STE B
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-5509
Practice Address - Country:US
Practice Address - Phone:949-409-4080
Practice Address - Fax:949-284-9200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-20
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty