Healthcare Provider Details

I. General information

NPI: 1548588486
Provider Name (Legal Business Name): FARAZ FRED LAALY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2010
Last Update Date: 05/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 N FIGUEROA ST
LOS ANGELES CA
90065-3013
US

IV. Provider business mailing address

3650 W CLARK AVE APT A
BURBANK CA
91505-2952
US

V. Phone/Fax

Practice location:
  • Phone: 323-223-1517
  • Fax: 323-223-1528
Mailing address:
  • Phone: 310-210-6955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number43626
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: