Healthcare Provider Details

I. General information

NPI: 1871107102
Provider Name (Legal Business Name): OFFICE OF DR. PAKRAVAN DDS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2020
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2136 UNIVERSITY AVE
BERKELEY CA
94704-1026
US

IV. Provider business mailing address

2136 UNIVERSITY AVE
BERKELEY CA
94704-1026
US

V. Phone/Fax

Practice location:
  • Phone: 510-548-3368
  • Fax: 510-259-2496
Mailing address:
  • Phone: 510-548-3368
  • Fax: 510-259-2496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. ANTHONY NEEDHAM
Title or Position: OWNER
Credential: DDS
Phone: 510-548-3368