Healthcare Provider Details

I. General information

NPI: 1629152251
Provider Name (Legal Business Name): ROBERT MINOOFAR D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9518 HUNT CLUB LN
CHATSWORTH CA
91311-2683
US

IV. Provider business mailing address

14976 FOOTHILL BLVD STE 100
FONTANA CA
92335-7045
US

V. Phone/Fax

Practice location:
  • Phone: 310-709-5251
  • Fax:
Mailing address:
  • Phone: 909-350-8730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number045534
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4844T
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number50079
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: