Healthcare Provider Details

I. General information

NPI: 1750054490
Provider Name (Legal Business Name): FARHAD MANAVI PROFESSIONAL DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2021
Last Update Date: 07/28/2021
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7910 NORWALK BLVD
WHITTIER CA
90606-2196
US

IV. Provider business mailing address

12121 WILSHIRE BLVD STE 1111
LOS ANGELES CA
90025-1188
US

V. Phone/Fax

Practice location:
  • Phone: 562-699-0343
  • Fax:
Mailing address:
  • Phone: 310-820-9933
  • Fax: 310-820-0408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MIGUEL REYES
Title or Position: Q/A CONTRACTS AND COMPLIANCE MANAGE
Credential:
Phone: 310-409-4225