Healthcare Provider Details

I. General information

NPI: 1144436494
Provider Name (Legal Business Name): P M KASROVI DDS MS A PROF DENTAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 ENSENADA AVE
BERKELEY CA
94705
US

IV. Provider business mailing address

3010 COLBY ST #220
BERKELEY CA
94705
US

V. Phone/Fax

Practice location:
  • Phone: 510-204-8856
  • Fax:
Mailing address:
  • Phone: 510-204-8856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number40362
License Number StateCA

VIII. Authorized Official

Name: DR. PAUL M KASROVI
Title or Position: PRESIDENT
Credential: DDS MS
Phone: 510-204-8856