Provider Demographics
NPI:1588038327
Name:SOROUSHIAN AND TAQAVI DENTAL CORPORATION
Entity Type:Organization
Organization Name:SOROUSHIAN AND TAQAVI DENTAL CORPORATION
Other - Org Name:GRACE DENTAL OF MODESTO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:POOYA
Authorized Official - Middle Name:
Authorized Official - Last Name:SOROOSHIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-876-4680
Mailing Address - Street 1:3125 COFFEE RD STE 4
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-1768
Mailing Address - Country:US
Mailing Address - Phone:209-526-8182
Mailing Address - Fax:209-526-8214
Practice Address - Street 1:3125 COFFEE RD STE 4
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-1768
Practice Address - Country:US
Practice Address - Phone:209-526-8182
Practice Address - Fax:209-526-8214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty