Healthcare Provider Details

I. General information

NPI: 1487133989
Provider Name (Legal Business Name): PAKRAVAN, MANAVI ADN COHEN DENTAL- SAN JOE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2018
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3571 N 1ST ST STE 203
SAN JOSE CA
95134-1803
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 408-424-2200
  • Fax: 408-770-1874
Mailing address:
  • Phone: 310-409-4225
  • Fax: 310-820-0408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

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