Provider Demographics
NPI:1235623190
Name:KOHAN & RODEF DENTAL CORPORATION
Entity Type:Organization
Organization Name:KOHAN & RODEF DENTAL CORPORATION
Other - Org Name:CHILDRENS DENTAL FUNZONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:FARIBORZ
Authorized Official - Middle Name:
Authorized Official - Last Name:RODEF
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-966-3033
Mailing Address - Street 1:2233 E. GARVEY AVE N.
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791
Mailing Address - Country:US
Mailing Address - Phone:626-966-3033
Mailing Address - Fax:626-214-0037
Practice Address - Street 1:500 SAN FERNARDO MISSION BLVD SUITE #2
Practice Address - Street 2:
Practice Address - City:SAN FERNARDO
Practice Address - State:CA
Practice Address - Zip Code:91340
Practice Address - Country:US
Practice Address - Phone:626-966-3033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KOHAN & RODEF DENTAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62906122300000X
CA383561223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty