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General NPI Number Information
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NPI Number | 1013577071
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Entity Type | Organization
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Legal Business Name | EDALAT DDS INC.
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Dates
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Enumeration Date | 06/20/2019
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Last Update Date | 08/30/2019
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Provider Practice Location Address
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Address Line | 130 AVENIDA CABRILLO STE B
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City | SAN CLEMENTE
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State | CA
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Zip | 92672-5509
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Country | US
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Telephone | 949-409-4080
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Fax | 949-284-9200
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Provider Business Mailing Address
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Address Line | 18625 BROOKHURST ST
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City | FOUNTAIN VALLEY
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State | CA
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Zip | 92708-6748
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Country | US
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Telephone | 949-409-4080
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Fax | 949-284-9200
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Authorized Official
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Title or Position | ENDODONTIST-OWNER
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Name | DR. HOSSEIN EDALAT
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Credential | DDS
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Telephone | 310-999-8777
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number |
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License Number State |
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