Provider Demographics
NPI:1558804799
Name:FOROUTAN DENTISTRY, INC
Entity Type:Organization
Organization Name:FOROUTAN DENTISTRY, INC
Other - Org Name:NEWPORT BEACH DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:FARZAD
Authorized Official - Middle Name:
Authorized Official - Last Name:FOROUTAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-644-9181
Mailing Address - Street 1:1401 AVOCADO AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7720
Mailing Address - Country:US
Mailing Address - Phone:949-644-9181
Mailing Address - Fax:949-644-0521
Practice Address - Street 1:1401 AVOCADO AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7720
Practice Address - Country:US
Practice Address - Phone:949-644-9181
Practice Address - Fax:949-644-0521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44476122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty