=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376707661
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAFAEDDIN JAHANBANI D.D.S., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2008
-----------------------------------------------------
Last Update Date | 07/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 113 WATERWORKS WAY STE 130
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-3168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-836-7831
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 113 WATERWORKS WAY STE 130
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-3168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-836-7831
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SAFAEDDIN JAHANBANI
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 949-836-7831
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 45376
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------