Healthcare Provider Details

I. General information

NPI: 1356565758
Provider Name (Legal Business Name): FARHAD MANAVI PROFESSIONAL DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5162 EAST WHITTIER BLVD
LOS ANGELES CA
90022
US

IV. Provider business mailing address

5162 EAST WHITTIER BLVD
LOS ANGELES CA
90022
US

V. Phone/Fax

Practice location:
  • Phone: 323-415-6161
  • Fax: 323-415-0675
Mailing address:
  • Phone: 323-415-6161
  • Fax: 323-415-0675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number38558
License Number StateCA

VIII. Authorized Official

Name: FARHAD MANAVI
Title or Position: OWNER
Credential:
Phone: 323-415-6161