Healthcare Provider Details

I. General information

NPI: 1992251516
Provider Name (Legal Business Name): POOYA SOLTANZADEH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 10/06/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8101 E KAISER BLVD STE 120
ANAHEIM CA
92808-2261
US

IV. Provider business mailing address

8101 E KAISER BLVD STE 120
ANAHEIM CA
92808-2261
US

V. Phone/Fax

Practice location:
  • Phone: 714-974-0949
  • Fax: 714-974-1310
Mailing address:
  • Phone: 714-974-0949
  • Fax: 714-974-1310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number102464
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: