=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730320250
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FARNAZ FARHIDPOUR DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2009
-----------------------------------------------------
Last Update Date | 12/13/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13768 ROSWELL AVE SUITE 110
-----------------------------------------------------
City | CHINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91710-1401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-902-1212
-----------------------------------------------------
Fax | 909-902-1213
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13768 ROSWELL AVE SUITE 110
-----------------------------------------------------
City | CHINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91710-1401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-902-1212
-----------------------------------------------------
Fax | 909-902-1213
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 48519
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------