Healthcare Provider Details

I. General information

NPI: 1124853072
Provider Name (Legal Business Name): MAVERICK BANI, D.D.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2024
Last Update Date: 09/02/2024
Certification Date: 09/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 N LAKE AVE
PASADENA CA
91104-4558
US

IV. Provider business mailing address

620 N ARDEN DR
BEVERLY HILLS CA
90210-3510
US

V. Phone/Fax

Practice location:
  • Phone: 626-797-8900
  • Fax:
Mailing address:
  • Phone: 310-993-0417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MAVERICK BANI
Title or Position: PRESIDENT
Credential: DDS
Phone: 310-993-0417