Healthcare Provider Details

I. General information

NPI: 1083844468
Provider Name (Legal Business Name): NABIZADEH DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2009
Last Update Date: 01/31/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7111 WINNETKA AVE STE 3
WINNETKA CA
91306-3673
US

IV. Provider business mailing address

7111 WINNETKA AVE STE 3
WINNETKA CA
91306-3673
US

V. Phone/Fax

Practice location:
  • Phone: 310-435-7586
  • Fax:
Mailing address:
  • Phone: 310-435-7586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number56220
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number56220
License Number StateCA

VIII. Authorized Official

Name: DR. BENNY NABIZADEH
Title or Position: DENTIST
Credential: DMD
Phone: 310-435-7586