Provider Demographics
NPI:1518666049
Name:RODEF DENTAL OFFICE OF SANTA CLARITA
Entity Type:Organization
Organization Name:RODEF DENTAL OFFICE OF SANTA CLARITA
Other - Org Name:CHILDRENS DENTAL FUNZONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FAIRBORZ
Authorized Official - Middle Name:
Authorized Official - Last Name:RODEF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-412-0200
Mailing Address - Street 1:2235A E. GARVEY AVE N.
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791-1540
Mailing Address - Country:US
Mailing Address - Phone:626-412-0200
Mailing Address - Fax:
Practice Address - Street 1:16658 SOLEDAD CANYON RD.
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91387-3217
Practice Address - Country:US
Practice Address - Phone:626-412-0200
Practice Address - Fax:661-383-0047
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RODEF & NASSIRIPOUR DENTAL OFFICE OF SANTA CLARITA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-02-23
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty