Provider Demographics
NPI:1952791816
Name:KEYVAN SADAGHIANI-AVAL, DDS A PROFESSIONAL CORPORATION.
Entity Type:Organization
Organization Name:KEYVAN SADAGHIANI-AVAL, DDS A PROFESSIONAL CORPORATION.
Other - Org Name:FALLBROOK DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GHIANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-486-1909
Mailing Address - Street 1:6739 3/4 FALLBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-3522
Mailing Address - Country:US
Mailing Address - Phone:818-592-6060
Mailing Address - Fax:818-592-8306
Practice Address - Street 1:6739 3/4 FALLBROOK AVE
Practice Address - Street 2:
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91307-3522
Practice Address - Country:US
Practice Address - Phone:818-592-6060
Practice Address - Fax:818-592-8306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-30
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00022G1335-001-21223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty