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General NPI Number Information
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NPI Number | 1790823698
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Entity Type | Organization
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Legal Business Name | HEAVENLY DENTAL
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Dates
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Enumeration Date | 02/02/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 321 N MACLAY AVE SUITE A
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City | SAN FERNANDO
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State | CA
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Zip | 91340
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Country | US
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Telephone | 818-837-9744
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Fax | 818-837-9303
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Provider Business Mailing Address
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Address Line | 321 N MACLAY AVE SUITE A
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City | SAN FERNANDO
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State | CA
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Zip | 91340
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Country | US
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Telephone | 818-837-9744
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Fax | 818-837-9303
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Authorized Official
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Title or Position | OWNER
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Name | NOUSHIN FANI
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Credential | DDS
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Telephone | 818-837-9744
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 39149
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License Number State | CA
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