=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255993135
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REZA A. TAFRESHI DDS,INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2019
-----------------------------------------------------
Last Update Date | 07/01/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 MAREBLU STE 360
-----------------------------------------------------
City | ALISO VIEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92656-3057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-360-9700
-----------------------------------------------------
Fax | 949-362-5182
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 MAREBLU STE 360
-----------------------------------------------------
City | ALISO VIEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92656-3057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-360-9700
-----------------------------------------------------
Fax | 949-362-5182
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | DR. REZA ABAEI TAFRESHI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 949-433-4768
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------