Healthcare Provider Details

I. General information

NPI: 1336877430
Provider Name (Legal Business Name): NAOMI BRIANNE BOUAZIZ DMD, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2022
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2233 E GARVEY AVE N
WEST COVINA CA
91791-1500
US

IV. Provider business mailing address

100 CUTTERMILL RD APT 4E
GREAT NECK NY
11021-3116
US

V. Phone/Fax

Practice location:
  • Phone: 626-605-0168
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDDS112749
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: