Healthcare Provider Details

I. General information

NPI: 1851584718
Provider Name (Legal Business Name): FOROUZAN YAVARI DDS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2007
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 MAREBLU SUITE #320
ALISO VIEJO CA
92656-3015
US

IV. Provider business mailing address

15 MAREBLU SUITE #320
ALISO VIEJO CA
92656-3015
US

V. Phone/Fax

Practice location:
  • Phone: 949-362-9888
  • Fax:
Mailing address:
  • Phone: 949-362-9888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number44558
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. FOROUZAN YAVARI
Title or Position: DENTIST
Credential: DDS
Phone: 949-362-9888