=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669747192
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAYDAR DENTAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2012
-----------------------------------------------------
Last Update Date | 10/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6071 MAGNOLIA AVE
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-680-1777
-----------------------------------------------------
Fax | 951-680-1776
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6071 MAGNOLIA AVE
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-680-1777
-----------------------------------------------------
Fax | 951-680-1776
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. AZITA PAYDAR
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 951-680-1777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 39865
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------