Provider Demographics
NPI:1073032165
Name:SOROUR DENTAL GROUP CORP
Entity Type:Organization
Organization Name:SOROUR DENTAL GROUP CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:SELVANA
Authorized Official - Middle Name:
Authorized Official - Last Name:SOROUR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:310-795-3363
Mailing Address - Street 1:13340 HAWTHORNE BLVD
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-5805
Mailing Address - Country:US
Mailing Address - Phone:310-795-3363
Mailing Address - Fax:
Practice Address - Street 1:3173 TWEEDY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-5739
Practice Address - Country:US
Practice Address - Phone:323-564-4554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-11
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty