Provider Demographics
NPI:1740766146
Name:ROBLES RODEF & YAGHOUBI DENTAL CORPORATION
Entity Type:Organization
Organization Name:ROBLES RODEF & YAGHOUBI DENTAL CORPORATION
Other - Org Name:CHILDRENS DENTAL FUNZONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:FARIBORZ
Authorized Official - Middle Name:
Authorized Official - Last Name:RODEF
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-412-0200
Mailing Address - Street 1:2233 E GARVEY AVE N
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791
Mailing Address - Country:US
Mailing Address - Phone:626-966-3033
Mailing Address - Fax:626-214-0037
Practice Address - Street 1:5628 VAN BUREN BLVD SUITE #A
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503
Practice Address - Country:US
Practice Address - Phone:310-625-3773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROBLES BOZORGMANESH RODEF & YAGHOUBI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-18
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56506122300000X
CA64776122300000X
CA58304122300000X
CA383561223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty