Provider Demographics
NPI:1083912430
Name:COHEN SEDGH, MANAVI& PAKRAVAN DENTAL CORPORATION
Entity Type:Organization
Organization Name:COHEN SEDGH, MANAVI& PAKRAVAN DENTAL CORPORATION
Other - Org Name:CANYON DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FARHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:MANAVI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-820-9933
Mailing Address - Street 1:28237 NEWHALL RANCH RD
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-0986
Mailing Address - Country:US
Mailing Address - Phone:661-257-4242
Mailing Address - Fax:661-294-0020
Practice Address - Street 1:28237 NEWHALL RANCH RD
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-0986
Practice Address - Country:US
Practice Address - Phone:661-257-4242
Practice Address - Fax:661-294-0020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-09
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38558122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty