Healthcare Provider Details

I. General information

NPI: 1629543228
Provider Name (Legal Business Name): ALBOORZ, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2018
Last Update Date: 10/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 KEENAN ST
WATERTOWN MA
02472-2904
US

IV. Provider business mailing address

1500 PASEO DE ORO
PACIFIC PALISADES CA
90272-1962
US

V. Phone/Fax

Practice location:
  • Phone: 310-401-4300
  • Fax:
Mailing address:
  • Phone: 310-401-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code292200000X
TaxonomyDental Laboratory
License Number
License Number State

VIII. Authorized Official

Name: DR. MOHAMAD A YAZDI
Title or Position: MEMBER
Credential: DDS, PHD
Phone: 310-401-4300