=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710178082
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL GROUP OF HESPERIA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2007
-----------------------------------------------------
Last Update Date | 08/05/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15776 MAIN ST STE 18
-----------------------------------------------------
City | HESPERIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92345-3461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-949-8484
-----------------------------------------------------
Fax | 760-949-3122
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 55368
-----------------------------------------------------
City | VALENCIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91385-0368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-255-3130
-----------------------------------------------------
Fax | 661-451-5248
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SEAN SOHAIL HAKIMI
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 661-255-3130
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 39643
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------