Healthcare Provider Details

I. General information

NPI: 1962625418
Provider Name (Legal Business Name): FARHAD MANAVI, D.D.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4149 TWEEDY BLVD STE G
SOUTH GATE CA
90280-6167
US

IV. Provider business mailing address

4149 TWEEDY BLVD STE G
SOUTH GATE CA
90280-6167
US

V. Phone/Fax

Practice location:
  • Phone: 323-567-3333
  • Fax: 323-567-2929
Mailing address:
  • Phone: 323-567-3333
  • Fax: 323-567-2929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number38558
License Number StateCA

VIII. Authorized Official

Name: FARHAD MANAVI
Title or Position: OWNER
Credential: DDS
Phone: 323-567-3333