Healthcare Provider Details

I. General information

NPI: 1639624463
Provider Name (Legal Business Name): POULDAR KIMIA AND LORENZ DENTAL PARTNERSHIP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2016
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14912 BURBANK BLVD
SHERMAN OAKS CA
91411-3609
US

IV. Provider business mailing address

14912 BURBANK BLVD
SHERMAN OAKS CA
91411-3609
US

V. Phone/Fax

Practice location:
  • Phone: 480-619-1415
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number61127
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number61270
License Number StateCA

VIII. Authorized Official

Name: DR. DARA KIMIA
Title or Position: PRESIDENT
Credential:
Phone: 480-619-1415