=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114257235
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AZITA S. EBRAHIMI DDS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2010
-----------------------------------------------------
Last Update Date | 01/12/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25662 CROWN VALLEY PKWY STE H4
-----------------------------------------------------
City | LADERA RANCH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92694-0486
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-276-2990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25662 CROWN VALLEY PKWY STE H4
-----------------------------------------------------
City | LADERA RANCH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92694-0486
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-276-2990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, PRESIDENT
-----------------------------------------------------
Name | DR. AZITA SHEILA EBRAHIMI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 949-276-2990
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 52505
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------