Provider Demographics
NPI:1295925634
Name:PETALUMA FAMILY DENTAL CARE
Entity type:Organization
Organization Name:PETALUMA FAMILY DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAKIMI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:661-255-3130
Mailing Address - Street 1:PO BOX 55368
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91385-0368
Mailing Address - Country:US
Mailing Address - Phone:661-255-3130
Mailing Address - Fax:661-451-5248
Practice Address - Street 1:35 MARIA DR
Practice Address - Street 2:STE 854
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-3548
Practice Address - Country:US
Practice Address - Phone:707-763-3203
Practice Address - Fax:707-763-3121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39643122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty