=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134368491
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAGHATCHI DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2009
-----------------------------------------------------
Last Update Date | 10/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1835 NEWPORT BLVD STE E267
-----------------------------------------------------
City | COSTA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92627-5013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-574-0100
-----------------------------------------------------
Fax | 949-574-0101
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1835 NEWPORT BLVD STE E267
-----------------------------------------------------
City | COSTA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92627-5013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-574-0100
-----------------------------------------------------
Fax | 949-574-0101
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. FARSHAD SAGHATCHI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-574-0100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 49877
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 45970
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------