Provider Demographics
NPI:1942713417
Name:PAKRAVAN DENTAL CORPORATION
Entity Type:Organization
Organization Name:PAKRAVAN DENTAL CORPORATION
Other - Org Name:WEST COAST DENTAL GROUP OF NORCO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:Q/A CONTRACT COMPLIANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-409-4225
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 1:2440 RIVER ROAD
Practice Address - Street 2:SUITE 140
Practice Address - City:NORCO
Practice Address - State:CA
Practice Address - Zip Code:92860
Practice Address - Country:US
Practice Address - Phone:310-820-9933
Practice Address - Fax:310-820-0408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39862122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty