Provider Demographics
NPI:1730649955
Name:EBI NIKJOO DENTAL CORP
Entity Type:Organization
Organization Name:EBI NIKJOO DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EBI
Authorized Official - Middle Name:DONAVAN
Authorized Official - Last Name:NIKJOO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:562-422-1000
Mailing Address - Street 1:5399 ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90805-6017
Mailing Address - Country:US
Mailing Address - Phone:562-422-1000
Mailing Address - Fax:
Practice Address - Street 1:5399 ORANGE AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805-6017
Practice Address - Country:US
Practice Address - Phone:562-422-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental