Healthcare Provider Details

I. General information

NPI: 1427430016
Provider Name (Legal Business Name): FARZAD MAZLOOMI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2015
Last Update Date: 04/13/2020
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8330 LONG BEACH BLVD STE 107
SOUTH GATE CA
90280-2073
US

IV. Provider business mailing address

8330 LONG BEACH BLVD STE 107
SOUTH GATE CA
90280-2073
US

V. Phone/Fax

Practice location:
  • Phone: 847-701-1457
  • Fax: 847-496-4850
Mailing address:
  • Phone: 323-582-5411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number102653
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: