Provider Demographics
NPI:1811614399
Name:FARID PAKRAVAN PROFESSIONAL DENTAL CORPORATION
Entity type:Organization
Organization Name:FARID PAKRAVAN PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING 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:
Practice Address - Street 1:10639 CARMENITA RD UNIT 7
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-4017
Practice Address - Country:US
Practice Address - Phone:310-820-9933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty