Provider Demographics
NPI:1437762523
Name:KOUSHAN AZAD DMD INC
Entity Type:Organization
Organization Name:KOUSHAN AZAD DMD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KOUSHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AZAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-698-3017
Mailing Address - Street 1:1009 N H ST STE P
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-8141
Mailing Address - Country:US
Mailing Address - Phone:805-698-3017
Mailing Address - Fax:
Practice Address - Street 1:238 E BETTERAVIA RD STE C
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-7889
Practice Address - Country:US
Practice Address - Phone:805-242-4881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-28
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty