Healthcare Provider Details

I. General information

NPI: 1326531658
Provider Name (Legal Business Name): GOLNAZ KAVAND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 CASE RD BLDG C
PERRIS CA
92570-5552
US

IV. Provider business mailing address

3838 DUNN DR APT 608
CULVER CITY CA
90232-2776
US

V. Phone/Fax

Practice location:
  • Phone: 951-345-4386
  • Fax:
Mailing address:
  • Phone: 319-400-3949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30.024640
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number106090
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number30.024640
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: