Provider Demographics
NPI:1689087199
Name:ROBERT BOOTEHSAZ DMD INC
Entity Type:Organization
Organization Name:ROBERT BOOTEHSAZ DMD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BOOTEHSAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:818-304-8021
Mailing Address - Street 1:19458 VENTURA BLVD. STE 10
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3042
Mailing Address - Country:US
Mailing Address - Phone:818-304-8021
Mailing Address - Fax:818-304-8029
Practice Address - Street 1:19458 VENTURA BLVD STE 10
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3037
Practice Address - Country:US
Practice Address - Phone:818-304-8021
Practice Address - Fax:818-304-8029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56953261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental