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General NPI Number Information
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NPI Number | 1245553072
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Entity Type | Organization
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Legal Business Name | FAMILY ORTHODONTICS
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Dates
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Enumeration Date | 03/08/2010
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Last Update Date | 03/08/2010
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Provider Practice Location Address
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Address Line | 1101 BRYAN AVE SUITE C
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City | TUSTIN
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State | CA
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Zip | 92780-4401
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Country | US
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Telephone | 714-544-0200
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Fax |
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Provider Business Mailing Address
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Address Line | 1101 BRYAN AVE SUITE C
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City | TUSTIN
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State | CA
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Zip | 92780-4401
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Country | US
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Telephone | 714-544-0200
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Fax |
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Authorized Official
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Title or Position | ORTHODONTIST/OWNER
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Name | EZZ DEAN AZZEH
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Credential |
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Telephone | 714-544-0200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 55883
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License Number State | CA
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