Provider Demographics
NPI:1407205065
Name:US ARMY
Entity Type:Organization
Organization Name:US ARMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FARZAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:POURANFAR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-409-2981
Mailing Address - Street 1:1320 TRUEMPER ST UNIT 369401
Mailing Address - Street 2:JBSA LACKLAND AFB
Mailing Address - City:LACKLAND AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78236-6094
Mailing Address - Country:US
Mailing Address - Phone:502-409-2981
Mailing Address - Fax:
Practice Address - Street 1:1320 TRUEMPER ST UNIT 369401
Practice Address - Street 2:JBSA LACKLAND AFB
Practice Address - City:LACKLAND AFB
Practice Address - State:TX
Practice Address - Zip Code:78236-6094
Practice Address - Country:US
Practice Address - Phone:502-409-2981
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-05
Last Update Date:2016-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9175305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service