Provider Demographics
NPI:1598168759
Name:ALICIA PKWY DENTAL
Entity Type:Organization
Organization Name:ALICIA PKWY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:G
Authorized Official - Last Name:FARZIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-587-3010
Mailing Address - Street 1:25401 ALICIA PKWY STE J
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-4958
Mailing Address - Country:US
Mailing Address - Phone:949-587-3010
Mailing Address - Fax:949-215-3757
Practice Address - Street 1:25401 ALICIA PKWY STE J
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-4958
Practice Address - Country:US
Practice Address - Phone:949-587-3010
Practice Address - Fax:949-215-3757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-02
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA535951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty