Provider Demographics
NPI:1104193051
Name:ADVANTA DENTAL GROUP
Entity Type:Organization
Organization Name:ADVANTA DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SEPIDEH
Authorized Official - Middle Name:
Authorized Official - Last Name:RAZAVI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:510-596-9000
Mailing Address - Street 1:5915 HOLLIS ST STE A
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-2066
Mailing Address - Country:US
Mailing Address - Phone:510-596-9000
Mailing Address - Fax:510-596-8800
Practice Address - Street 1:5915 HOLLIS ST STE A
Practice Address - Street 2:
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-2066
Practice Address - Country:US
Practice Address - Phone:510-596-9000
Practice Address - Fax:510-596-8800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42496122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA42496OtherDENTAL LICENSE