=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043646698
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROZBEH HOSSIENI DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2013
-----------------------------------------------------
Last Update Date | 11/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15182 N 75TH AVE STE 280
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85381-4722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-564-4991
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1541 S CARRIAGE LN
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85286-6708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-206-8077
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 62878
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 10410
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------