=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083295943
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOJDEH FARAZ DDS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2021
-----------------------------------------------------
Last Update Date | 04/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 230 GREEN VALLEY RD
-----------------------------------------------------
City | FREEDOM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95019-3136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-722-9202
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 230 GREEN VALLEY RD
-----------------------------------------------------
City | FREEDOM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95019-3136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-722-9202
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST-OWNER
-----------------------------------------------------
Name | DR. MOJDEH FARAZ
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 949-315-5216
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------