=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013615699
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARISA DENTAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2023
-----------------------------------------------------
Last Update Date | 02/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8599 HAVEN AVE STE 105
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-4849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-945-2342
-----------------------------------------------------
Fax | 909-948-5474
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8599 HAVEN AVE STE 105
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-4849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-945-2342
-----------------------------------------------------
Fax | 909-948-5474
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. PARISA GHEIDARPOUR
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 909-254-7032
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------