Healthcare Provider Details

I. General information

NPI: 1922283936
Provider Name (Legal Business Name): FARID PAKRAVAN PROFESSIONAL DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2008
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 W AVENUE K STE 105
LANCASTER CA
93534-6429
US

IV. Provider business mailing address

12121 WILSHIRE BLVD STE 1111
LOS ANGELES CA
90025-1188
US

V. Phone/Fax

Practice location:
  • Phone: 661-723-1111
  • Fax: 661-726-0587
Mailing address:
  • Phone: 310-820-9933
  • Fax: 310-820-0408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number39862
License Number StateCA

VIII. Authorized Official

Name: FARID PAKRAVAN
Title or Position: OWNER
Credential:
Phone: 310-820-9933