Provider Demographics
NPI:1780205047
Name:FARIBORZ RODEF DENTAL CORPORATION
Entity Type:Organization
Organization Name:FARIBORZ RODEF DENTAL CORPORATION
Other - Org Name:CHILDRENS DENTAL FUNZONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FARIBORZ
Authorized Official - Middle Name:
Authorized Official - Last Name:RODEF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-412-0200
Mailing Address - Street 1:2225 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:626-412-0200
Mailing Address - Fax:626-214-0037
Practice Address - Street 1:233 SOUTH FREMONT AVE
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801
Practice Address - Country:US
Practice Address - Phone:626-412-0200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FARIBORZ RODEF DENTAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-04-28
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty