=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275343204
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FUSION ORTHODONTICS AT GARLAND
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2025
-----------------------------------------------------
Last Update Date | 01/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 S 1ST ST STE A
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75040-7219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-544-0032
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 107 S 1ST ST STE A
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75040-7219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-544-0032
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORTHODONTIST
-----------------------------------------------------
Name | DR. HESSAM RAHIMI
-----------------------------------------------------
Credential | DDS, DMSC, MBA
-----------------------------------------------------
Telephone | 310-666-5730
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------