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General NPI Number Information
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NPI Number | 1548730450
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Entity Type | Organization
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Legal Business Name | MASTOUR & FARD DENTAL CORP
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Dates
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Enumeration Date | 12/04/2018
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Last Update Date | 10/23/2019
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Provider Practice Location Address
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Address Line | 587 N. VENTU PARK ROAD. SUITE C
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City | NEWBERRY PARK
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State | CA
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Zip | 91320
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Country | US
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Telephone | 805-499-1253
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Fax | 805-499-1453
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Provider Business Mailing Address
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Address Line | 5620 SAWTELLE BLVD
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City | CULVER CITY
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State | CA
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Zip | 90230-5508
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Country | US
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Telephone | 310-390-6212
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Fax | 310-390-6215
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Authorized Official
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Title or Position | OWNER
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Name | PEDRAM MASTOUR
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Credential | DDS
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Telephone | 310-804-0414
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number |
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License Number State |
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