=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316683022
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORWALK DENTAL OFFICE OF ALBORZ MEHDIZADEH INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2022
-----------------------------------------------------
Last Update Date | 05/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12100 IMPERIAL HWY # 101A
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90650-3081
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-210-8576
-----------------------------------------------------
Fax | 562-210-8601
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12100 IMPERIAL HWY # 101A
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90650-3081
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-210-8576
-----------------------------------------------------
Fax | 562-210-8601
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ALBORZ MEHDIZADEH
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 818-913-8097
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------