Healthcare Provider Details

I. General information

NPI: 1659964872
Provider Name (Legal Business Name): POYOUROW PROFESSIONAL DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2021
Last Update Date: 02/18/2021
Certification Date: 02/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 AVOCADO AVE STE 406
NEWPORT BEACH CA
92660-7705
US

IV. Provider business mailing address

4582 KATELLA AVE
LOS ALAMITOS CA
90720-2655
US

V. Phone/Fax

Practice location:
  • Phone: 949-760-1601
  • Fax:
Mailing address:
  • Phone: 310-279-0993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. SOLOMON POYOUROW
Title or Position: OWNER
Credential: DDS, MD, MPH
Phone: 310-279-0993