Provider Demographics
NPI:1093772139
Name:FOROUTAN, AUDREY A (DMD)
Entity Type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:A
Last Name:FOROUTAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 GARDEN VIEW CT
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-2464
Mailing Address - Country:US
Mailing Address - Phone:760-944-5588
Mailing Address - Fax:760-944-5688
Practice Address - Street 1:700 GARDEN VIEW CT
Practice Address - Street 2:SUITE 200
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2464
Practice Address - Country:US
Practice Address - Phone:760-944-5588
Practice Address - Fax:760-944-5688
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA493151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice