Healthcare Provider Details

I. General information

NPI: 1003692351
Provider Name (Legal Business Name): FARAN MASOUDI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2023
Last Update Date: 09/04/2023
Certification Date: 09/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 E CENTER AVE
VISALIA CA
93291-6331
US

IV. Provider business mailing address

1217 WILSHIRE BLVD # 3154
SANTA MONICA CA
90403-5466
US

V. Phone/Fax

Practice location:
  • Phone: 877-960-3426
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number109137
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: