Provider Demographics
NPI:1053831396
Name:FOROUTAN DENTAL CORP
Entity Type:Organization
Organization Name:FOROUTAN DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-644-9181
Mailing Address - Street 1:8951 KNOTT AVE STE L
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-4108
Mailing Address - Country:US
Mailing Address - Phone:714-826-4181
Mailing Address - Fax:
Practice Address - Street 1:8951 KNOTT AVE STE L
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-4108
Practice Address - Country:US
Practice Address - Phone:714-826-4181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-27
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty