Provider Demographics
NPI:1932705381
Name:FAILAEV, ITZHAK
Entity Type:Individual
Prefix:
First Name:ITZHAK
Middle Name:
Last Name:FAILAEV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 CREEK RD STE A150
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-4791
Mailing Address - Country:US
Mailing Address - Phone:949-825-7799
Mailing Address - Fax:
Practice Address - Street 1:33 CREEK RD STE A150
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-4791
Practice Address - Country:US
Practice Address - Phone:949-825-7799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1058291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice