Provider Demographics
NPI:1114257235
Name:AZITA S. EBRAHIMI DDS INC
Entity Type:Organization
Organization Name:AZITA S. EBRAHIMI DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AZITA
Authorized Official - Middle Name:SHEILA
Authorized Official - Last Name:EBRAHIMI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-276-2990
Mailing Address - Street 1:25662 CROWN VALLEY PKWY STE H4
Mailing Address - Street 2:
Mailing Address - City:LADERA RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92694-0486
Mailing Address - Country:US
Mailing Address - Phone:949-276-2990
Mailing Address - Fax:
Practice Address - Street 1:25662 CROWN VALLEY PKWY STE H4
Practice Address - Street 2:
Practice Address - City:LADERA RANCH
Practice Address - State:CA
Practice Address - Zip Code:92694-0486
Practice Address - Country:US
Practice Address - Phone:949-276-2990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52505261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental