Healthcare Provider Details

I. General information

NPI: 1063631109
Provider Name (Legal Business Name): F MOFTAKHAR DDS A PROFESSIONAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 E 12TH ST STE 163
OAKLAND CA
94601-2939
US

IV. Provider business mailing address

1809 E ECKERMAN AVE
WEST COVINA CA
91791-1112
US

V. Phone/Fax

Practice location:
  • Phone: 510-533-1123
  • Fax: 510-485-5109
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. FARSHAD MOFTAKHAR
Title or Position: OWNER CEO
Credential: DDS
Phone: 626-246-0150