Provider Demographics
NPI:1346365657
Name:SOPHIA ROZOV DDS, INC
Entity Type:Organization
Organization Name:SOPHIA ROZOV DDS, INC
Other - Org Name:SMILE AVENUE DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SOPHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROZOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:562-904-0400
Mailing Address - Street 1:5640 ETIWANDA AVE
Mailing Address - Street 2:# 5
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-2700
Mailing Address - Country:US
Mailing Address - Phone:562-904-0400
Mailing Address - Fax:562-904-1803
Practice Address - Street 1:8543 ROSEMEAD BLVD
Practice Address - Street 2:# D
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660-5427
Practice Address - Country:US
Practice Address - Phone:562-904-0400
Practice Address - Fax:562-904-1803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA458201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01-45820OtherDELTA-DENTAL
CAG93356-01OtherDENTI-CAL