Provider Demographics
NPI:1568668069
Name:FARIBA AHMADZADEH DENTAL CORP.
Entity Type:Organization
Organization Name:FARIBA AHMADZADEH DENTAL CORP.
Other - Org Name:PLAZA DENTAL CLI NIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:0WNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FARIBA
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMADZADEH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-780-8555
Mailing Address - Street 1:7028 VAN NUYS BLVD
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-3059
Mailing Address - Country:US
Mailing Address - Phone:818-780-8555
Mailing Address - Fax:818-780-8477
Practice Address - Street 1:7028 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3059
Practice Address - Country:US
Practice Address - Phone:818-780-8555
Practice Address - Fax:818-780-8477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45349122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty