Healthcare Provider Details

I. General information

NPI: 1346192622
Provider Name (Legal Business Name): SOCAL FACIAL PLASTIC SURGERY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 CONCOURS BLDG 3
ONTARIO CA
91764-4875
US

IV. Provider business mailing address

6800 INDIANA AVE STE 280
RIVERSIDE CA
92506-7205
US

V. Phone/Fax

Practice location:
  • Phone: 304-881-3170
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ADEEB DERAKHSHAN
Title or Position: SURGEON
Credential: MD
Phone: 951-783-9198