Healthcare Provider Details

I. General information

NPI: 1245606789
Provider Name (Legal Business Name): JAVAD AGHALOO DDS A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 01/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 S LA BRUCHERIE RD
EL CENTRO CA
92243-9495
US

IV. Provider business mailing address

1502 S LA BRUCHERIE RD
EL CENTRO CA
92243-9495
US

V. Phone/Fax

Practice location:
  • Phone: 760-482-5505
  • Fax: 760-482-5501
Mailing address:
  • Phone: 760-482-5505
  • Fax: 760-482-5501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number51184
License Number StateCA

VIII. Authorized Official

Name: DR. JAVAD SAGE AGHALOO
Title or Position: OWNER
Credential: DDS
Phone: 760-482-5505