MEDICARE: BRUCE VAFA DDS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	52126	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G93576-01	OTHER	CA	DENTICAL

General Provider Information

NPI Number	:	1386837599
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRUCE VAFA DDS, INC.

Provider Business Mailing Address
First Line	:	4341 LAUREL CANYON BLVD
Second Line	:
City	:	STUDIO CITY
State	:	CA
Zip	:	91604-1710
Country	:	US
Telephone Number	:	818-761-3230
Fax Number	:

Provider Business Practice Location Address
First Line	:	4341 LAUREL CANYON BLVD
Second Line	:
City	:	STUDIO CITY
State	:	CA
Zip	:	91604-1710
Country	:	US
Telephone Number	:	818-761-3230
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BRUCE VAFA
Credential	:	D.D.S
Telephone Number	:	818-761-3230

Provider Enumeration Date	:	08/21/2007
Last Update Date	:	04/09/2015

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