=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356086524
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | S. YOUSEFI DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2022
-----------------------------------------------------
Last Update Date | 05/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1104 W REDONDO BEACH BLVD
-----------------------------------------------------
City | GARDENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90247-3512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-872-2357
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1104 W REDONDO BEACH BLVD
-----------------------------------------------------
City | GARDENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90247-3512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | SANAZ YOUSEFI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-872-2357
-----------------------------------------------------
=====================================================
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 | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------