=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104420157
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAMAN GHAEMMAGHAMI DMD A PROFESSIONAL DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2020
-----------------------------------------------------
Last Update Date | 09/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4016 UNIVERSITY PKWY
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92407-1821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-880-1600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11540 CLARIDGE DR
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-7244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. SAMAN GHAEMMAGHAMI
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 408-930-4970
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------