Provider Demographics
NPI:1114158151
Name:RODEF & MOADEL DENTAL CORP
Entity Type:Organization
Organization Name:RODEF & MOADEL DENTAL CORP
Other - Org Name:CHILDRENS DENTAL FUNZONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:FARIBORZ
Authorized Official - Middle Name:
Authorized Official - Last Name:RODEF
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-412-0200
Mailing Address - Street 1:137 N MONEBELLO BLVD
Mailing Address - Street 2:#H
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-0000
Mailing Address - Country:US
Mailing Address - Phone:310-625-3773
Mailing Address - Fax:626-966-3063
Practice Address - Street 1:137 N MONEBELLO BLVD
Practice Address - Street 2:#H
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-0000
Practice Address - Country:US
Practice Address - Phone:310-625-3773
Practice Address - Fax:626-966-3063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-06
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA383561223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty