Healthcare Provider Details

I. General information

NPI: 1962811349
Provider Name (Legal Business Name): DONALD L IMAN DDS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2014
Last Update Date: 08/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23470 OLIVE WOOD PLAZA DR STE 170
MORENO VALLEY CA
92553-5267
US

IV. Provider business mailing address

23470 OLIVE WOOD PLAZA DR STE 170
MORENO VALLEY CA
92553-5267
US

V. Phone/Fax

Practice location:
  • Phone: 951-242-8426
  • Fax: 951-242-5639
Mailing address:
  • Phone: 951-242-8426
  • Fax: 951-242-5639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number30538
License Number StateCA

VIII. Authorized Official

Name: DR. DONALD LEE IMAN
Title or Position: OWNER/ CEO
Credential: DDS
Phone: 951-283-4626