Provider Demographics
NPI:1689118192
Name:BRUCE VAFA DDS DENTAL CORP
Entity Type:Organization
Organization Name:BRUCE VAFA DDS DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:VAFA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-201-9001
Mailing Address - Street 1:8500 WILSHIRE BLVD STE 709
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-3105
Mailing Address - Country:US
Mailing Address - Phone:310-201-9001
Mailing Address - Fax:310-289-9030
Practice Address - Street 1:8500 WILSHIRE BLVD STE 709
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-3105
Practice Address - Country:US
Practice Address - Phone:310-201-9001
Practice Address - Fax:310-289-9030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52126122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty