=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366746455
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NAVID TABIBZADEH DDS A DENTAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2011
-----------------------------------------------------
Last Update Date | 01/07/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13060 GLENOAKS BLVD STE 105-A
-----------------------------------------------------
City | SYLMAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91342-3966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-899-1800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13060 GLENOAKS BLVD STE 105-A
-----------------------------------------------------
City | SYLMAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91342-3963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-899-1800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | NAVID TABIBZADEH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-899-1800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 51140
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------