Provider Demographics
NPI:1114126984
Name:KAWEH FARAHBOD, D.D.S., A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:KAWEH FARAHBOD, D.D.S., A PROFESSIONAL CORP
Other - Org Name:FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAWEH
Authorized Official - Middle Name:
Authorized Official - Last Name:FARAHBOD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-893-1356
Mailing Address - Street 1:7689 WESTMINSTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-3921
Mailing Address - Country:US
Mailing Address - Phone:714-893-1356
Mailing Address - Fax:714-894-9387
Practice Address - Street 1:7689 WESTMINSTER BLVD
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-3921
Practice Address - Country:US
Practice Address - Phone:714-893-1356
Practice Address - Fax:714-894-9387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41724122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA685422OtherUNITED CONCORDIA
CAB41724-1Medicaid
CAD41724-01Medicaid
CA41724OtherDELTA DENTAL