=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558997148
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | S. SAFARIAN DMD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2020
-----------------------------------------------------
Last Update Date | 03/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 955 BOARDWALK STE 304
-----------------------------------------------------
City | SAN MARCOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92078-2659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-798-1768
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1040 TIERRA DEL REY STE 211
-----------------------------------------------------
City | CHULA VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91910-7865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-656-6785
-----------------------------------------------------
Fax | 619-656-6789
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SHAHIN SAFARIAN
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 858-349-7996
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223D0001X
-----------------------------------------------------
Taxonomy Name | Public Health Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------