Healthcare Provider Details

I. General information

NPI: 1740011121
Provider Name (Legal Business Name): GHANOUNI YASHARI DENTAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2024
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1737 PROFESSIONAL DR
SACRAMENTO CA
95825
US

IV. Provider business mailing address

1737 PROFESSIONAL DR
SACRAMENTO CA
95825
US

V. Phone/Fax

Practice location:
  • Phone: 916-545-5373
  • Fax:
Mailing address:
  • Phone: 916-545-5373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: SEPAND GHANOUNI
Title or Position: CHIEF FINANCIAL OFFICER
Credential: DDS
Phone: 916-545-5373