Provider Demographics
NPI:1477030351
Name:KOUSHAN AZAD DENTAL CORPOPRATION
Entity Type:Organization
Organization Name:KOUSHAN AZAD DENTAL CORPOPRATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:OLIVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:AGUINAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-808-7290
Mailing Address - Street 1:5903 ANNIE OAKLEY RD
Mailing Address - Street 2:
Mailing Address - City:HIDDEN HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-1230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3870 BROAD ST STE 1
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7172
Practice Address - Country:US
Practice Address - Phone:630-624-5788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental