=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508318916
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABRAHAM GHORBANIAN DDS DENTAL OFFICE OF SANTA ANA CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2016
-----------------------------------------------------
Last Update Date | 11/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2220 E FRUIT ST STE 111
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92701-4459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-481-0055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31 MUSICK
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-1638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-450-0076
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. ABRAHAM GHORBANIAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 949-450-0076
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 53515
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------