Healthcare Provider Details

I. General information

NPI: 1780396796
Provider Name (Legal Business Name): FARID PAKRAVAN PROFESSIONAL DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2022
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6423 VINELAND AVE
NORTH HOLLYWOOD CA
91606-2712
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 310-820-9933
  • Fax: 310-820-0408
Mailing address:
  • Phone: 310-820-9933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MIGUEL REYES
Title or Position: Q/A CONTRACT & COMPLIANCE MANAGER
Credential:
Phone: 310-409-4225