Provider Demographics
NPI:1114276631
Name:BABAK ETEMAD DMD INC
Entity Type:Organization
Organization Name:BABAK ETEMAD DMD INC
Other - Org Name:CASA DENTAL OF SANTA ANA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BABAK
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:ETEMAD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-541-0837
Mailing Address - Street 1:1334 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92703-3723
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1334 W 1ST ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92703-3723
Practice Address - Country:US
Practice Address - Phone:714-541-0837
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59028122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty