Healthcare Provider Details

I. General information

NPI: 1548535123
Provider Name (Legal Business Name): EBRAHIMIAN & EBRAHIMIAN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2012
Last Update Date: 03/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 ERBA LN STE A
SCOTTS VALLEY CA
95066-4160
US

IV. Provider business mailing address

5 ERBA LN STE A
SCOTTS VALLEY CA
95066-4160
US

V. Phone/Fax

Practice location:
  • Phone: 831-438-4411
  • Fax: 831-438-1323
Mailing address:
  • Phone: 831-438-4411
  • Fax: 831-438-1323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number28542
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number28543
License Number StateCA

VIII. Authorized Official

Name: DR. MAX EBRAHIMIAN
Title or Position: OWNER
Credential: DDS
Phone: 831-438-4411