Healthcare Provider Details

I. General information

NPI: 1902185846
Provider Name (Legal Business Name): RODEF DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2011
Last Update Date: 09/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9810 SIERRA AVE #D
FONTANA CA
92335-0000
US

IV. Provider business mailing address

9810 SIERRA AVE STE D
FONTANA CA
92335-6779
US

V. Phone/Fax

Practice location:
  • Phone: 310-625-3773
  • Fax: 626-966-3033
Mailing address:
  • Phone: 310-625-3773
  • Fax: 626-966-3033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number38356
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number38356
License Number StateCA

VIII. Authorized Official

Name: DR. FARIBORZ RODEF
Title or Position: PRESIDENT
Credential: DDS
Phone: 310-625-3773