Provider Demographics
NPI:1043494370
Name:RADMAND PROFESSIONAL DENTAL GROUP
Entity Type:Organization
Organization Name:RADMAND PROFESSIONAL DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REZA
Authorized Official - Middle Name:
Authorized Official - Last Name:RADMAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-385-3500
Mailing Address - Street 1:15720 VENTURA BLVD
Mailing Address - Street 2:609
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2914
Mailing Address - Country:US
Mailing Address - Phone:818-385-3500
Mailing Address - Fax:
Practice Address - Street 1:15720 VENTURA BLVD
Practice Address - Street 2:609
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2914
Practice Address - Country:US
Practice Address - Phone:818-385-3500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38118122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG91540-01OtherDENTICAL