=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760939912
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | M. ZAKER DDS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2016
-----------------------------------------------------
Last Update Date | 09/06/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8880 LIMONITE AVE
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92509-5021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-881-0393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8880 LIMONITE AVE
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92509-5021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-881-0393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MEYSAM ZAKER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 800-881-0393
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 57220
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------