Healthcare Provider Details

I. General information

NPI: 1215857404
Provider Name (Legal Business Name): LA VERNE MODERN DENTISTRY, PROF. CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 FOOTHILL BLVD
LA VERNE CA
91750-3434
US

IV. Provider business mailing address

PO BOX 660041
DALLAS TX
75266-0041
US

V. Phone/Fax

Practice location:
  • Phone: 909-906-3765
  • Fax: 909-962-8201
Mailing address:
  • Phone: 714-845-8890
  • Fax: 303-952-0892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ABANUB WASFY FARAG
Title or Position: OWNER
Credential: DDS
Phone: 909-906-3765