Healthcare Provider Details

I. General information

NPI: 1225451545
Provider Name (Legal Business Name): ROOBIK EBRAHIMI CDT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2014
Last Update Date: 01/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 BROADVIEW DR STE C
GLENDALE CA
91208-1355
US

IV. Provider business mailing address

2101 BROADVIEW DR STE C
GLENDALE CA
91208-1355
US

V. Phone/Fax

Practice location:
  • Phone: 818-957-0400
  • Fax: 818-957-0422
Mailing address:
  • Phone: 818-957-0400
  • Fax: 818-957-0422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126900000X
TaxonomyDental Laboratory Technician
License Number104616-00
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: