Healthcare Provider Details

I. General information

NPI: 1881997971
Provider Name (Legal Business Name): NEW AGE FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2010
Last Update Date: 12/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 E LOS ANGELES AVE SUITE #202
SIMI VALLEY CA
93065-2898
US

IV. Provider business mailing address

1350 E LOS ANGELES AVE SUITE #202
SIMI VALLEY CA
93065-2898
US

V. Phone/Fax

Practice location:
  • Phone: 805-520-6490
  • Fax: 805-520-9493
Mailing address:
  • Phone: 805-520-6490
  • Fax: 805-520-9493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. SHAHRAM HOSSEINI
Title or Position: OWNER
Credential: DENTIST, DDS
Phone: 805-520-6490