Healthcare Provider Details

I. General information

NPI: 1497020119
Provider Name (Legal Business Name): ROUHANI AND KHABBAZ DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2012
Last Update Date: 03/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 S LAKE AVE LOWER LEVEL
PASADENA CA
91101-3537
US

IV. Provider business mailing address

310 S LAKE AVE LOWER LEVEL
PASADENA CA
91101-3537
US

V. Phone/Fax

Practice location:
  • Phone: 626-795-6855
  • Fax: 626-432-4260
Mailing address:
  • Phone: 626-795-6855
  • Fax: 626-432-4260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number43654
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number43654
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number43654
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number43654
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number43654
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number43654
License Number StateCA
# 7
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number43654
License Number StateCA

VIII. Authorized Official

Name: DR. MORVARD ROUHANI
Title or Position: OWNER
Credential: D.D.S.
Phone: 626-795-6855