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General NPI Number Information
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NPI Number | 1386234284
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Entity Type | Organization
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Legal Business Name | PERIODONTICS, ORAL AND FACIAL SURGICAL SPECIALTIES
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Dates
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Enumeration Date | 01/25/2021
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Last Update Date | 01/25/2021
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Provider Practice Location Address
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Address Line | 29829 SANTA MARGARITA PKWY STE 300
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City | RANCHO SANTA MARGARITA
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State | CA
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Zip | 92688-3623
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Country | US
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Telephone | 949-888-0332
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Fax | 949-888-0400
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Provider Business Mailing Address
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Address Line | 29829 SANTA MARGARITA PKWY STE 300
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City | RANCHO SANTA MARGARITA
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State | CA
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Zip | 92688-3623
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Country | US
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Telephone | 949-888-0332
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Fax | 949-888-0400
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Authorized Official
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Title or Position | OWNER
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Name | DR. REZA BOLOURIAN
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Credential | MD
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Telephone | 949-888-0332
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QS0112X
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Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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