Healthcare Provider Details

I. General information

NPI: 1740857812
Provider Name (Legal Business Name): SEASIDE ORAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2021
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 DURIAN ST STE C
VISTA CA
92083-6240
US

IV. Provider business mailing address

360 E 1ST ST # 698
TUSTIN CA
92780-3211
US

V. Phone/Fax

Practice location:
  • Phone: 949-510-7795
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: ALI AMROLLAHIE
Title or Position: GENERAL PARTNER
Credential: DMD
Phone: 949-510-7795