Provider Demographics
NPI:1912367012
Name:RODEF DENTAL OFFICE OF RESEDA INC
Entity Type:Organization
Organization Name:RODEF DENTAL OFFICE OF RESEDA INC
Other - Org Name:CHILDRENS DENTAL FUNZONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
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 1:6846 RESEDA BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-8512
Mailing Address - Country:US
Mailing Address - Phone:310-625-3773
Mailing Address - Fax:
Practice Address - Street 1:6846 RESEDA BLVD STE C
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-8512
Practice Address - Country:US
Practice Address - Phone:310-625-3773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-02
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA383561223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty