Healthcare Provider Details

I. General information

NPI: 1528240587
Provider Name (Legal Business Name): ROSHANAK ROFAGHA D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2007
Last Update Date: 01/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 S MAIN ST
ORANGE CA
92868-4525
US

IV. Provider business mailing address

PO BOX 1037
LA CANADA CA
91012-1037
US

V. Phone/Fax

Practice location:
  • Phone: 818-926-1813
  • Fax: 818-249-1061
Mailing address:
  • Phone: 818-926-1813
  • Fax: 818-249-1061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number55766
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: