Healthcare Provider Details

I. General information

NPI: 1891968335
Provider Name (Legal Business Name): FAROKH ASHRAFIA KHATIBLOU DMD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2008
Last Update Date: 04/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 S MAIN STREET
ORANGE CA
92868
US

IV. Provider business mailing address

28044 MARGUERITE PKWY #K
MISSION VIEJO CA
92692
US

V. Phone/Fax

Practice location:
  • Phone: 714-571-3495
  • Fax:
Mailing address:
  • Phone:
  • Fax: 949-429-2783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number51836
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: