=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740694249
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FARD & MASTOUR DENTAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2014
-----------------------------------------------------
Last Update Date | 06/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15720 VENTURA BLVD SUITE 514
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-2914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-990-6659
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15720 VENTURA BLVD SUITE 514
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-2914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-990-6659
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ARASH SABBAGH FARD
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 818-990-6659
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 48007
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------