Healthcare Provider Details

I. General information

NPI: 1306348768
Provider Name (Legal Business Name): PAKRAVAN, MANAVI & COHEN DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2018
Last Update Date: 07/30/2020
Certification Date: 07/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7210 DAY CREEK BLVD SUITE 110
RANCHO CUCAMONGA CA
91739
US

IV. Provider business mailing address

12121 WILSHIRE BLVD STE 1111
LOS ANGELES CA
90025-1188
US

V. Phone/Fax

Practice location:
  • Phone: 310-820-9933
  • Fax: 310-820-0408
Mailing address:
  • Phone: 310-820-9933
  • Fax: 310-820-0408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number39862
License Number StateCA

VIII. Authorized Official

Name: MIGUEL REYES
Title or Position: Q/A CONTRACT & COMPLIANCE MANAGER
Credential:
Phone: 310-820-9933