=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710602867
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARA HARIRI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2022
-----------------------------------------------------
Last Update Date | 10/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15228 HAWTHORNE BLVD
-----------------------------------------------------
City | LAWNDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90260-2266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-481-1325
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1120 S GRAND AVE APT 2703
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90015-4660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 108079
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------