Healthcare Provider Details

I. General information

NPI: 1245176239
Provider Name (Legal Business Name): VAKILIAN-BAK DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2026
Last Update Date: 04/24/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 JENSEN CT STE 100
THOUSAND OAKS CA
91360-7406
US

IV. Provider business mailing address

115 JENSEN CT STE 100
THOUSAND OAKS CA
91360-7406
US

V. Phone/Fax

Practice location:
  • Phone: 805-497-2222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. POUYA VAKILIAN
Title or Position: OWNER
Credential: DMD,MD
Phone: 858-652-9521