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General NPI Number Information
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NPI Number | 1740857812
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Entity Type | Organization
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Legal Business Name | SEASIDE ORAL SURGERY
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Dates
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Enumeration Date | 06/08/2021
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Last Update Date | 06/08/2021
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Provider Practice Location Address
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Address Line | 105 DURIAN ST STE C
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City | VISTA
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State | CA
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Zip | 92083-6240
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Country | US
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Telephone | 949-510-7795
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Fax |
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Provider Business Mailing Address
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Address Line | 360 E 1ST ST # 698
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City | TUSTIN
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State | CA
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Zip | 92780-3211
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | GENERAL PARTNER
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Name | ALI AMROLLAHIE
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Credential | DMD
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Telephone | 949-510-7795
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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