=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477030351
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KOUSHAN AZAD DENTAL CORPOPRATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2018
-----------------------------------------------------
Last Update Date | 04/30/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3870 BROAD ST STE 1
-----------------------------------------------------
City | SAN LUIS OBISPO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93401-7172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-624-5788
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5903 ANNIE OAKLEY RD
-----------------------------------------------------
City | HIDDEN HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91302-1230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KOUSHAN AZAD
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 805-202-4988
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------