Provider Demographics
NPI:1922283936
Name:FARID PAKRAVAN PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:FARID PAKRAVAN PROFESSIONAL DENTAL CORPORATION
Other - Org Name:FAMILY DENTAL PRACTICE OF LANCASTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FARID
Authorized Official - Middle Name:
Authorized Official - Last Name:PAKRAVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-820-9933
Mailing Address - Street 1:12121 WILSHIRE BLVD STE 1111
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1188
Mailing Address - Country:US
Mailing Address - Phone:310-820-9933
Mailing Address - Fax:310-820-0408
Practice Address - Street 1:1025 W AVENUE K STE 105
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-6429
Practice Address - Country:US
Practice Address - Phone:661-723-1111
Practice Address - Fax:661-726-0587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA398621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty