Healthcare Provider Details

I. General information

NPI: 1225513583
Provider Name (Legal Business Name): AMANDA RAFI, DMD APDC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2018
Last Update Date: 02/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14591 NEWPORT AVE STE 108
TUSTIN CA
92780-6026
US

IV. Provider business mailing address

14591 NEWPORT AVE STE 108
TUSTIN CA
92780-6026
US

V. Phone/Fax

Practice location:
  • Phone: 480-510-8888
  • Fax:
Mailing address:
  • Phone: 949-771-7234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. AMANDA RAFI
Title or Position: OWNER
Credential: DMD
Phone: 480-510-8888