=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902629090
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | M. NEDJAT-HAIEM DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2024
-----------------------------------------------------
Last Update Date | 11/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 763 TOWN CENTER DR
-----------------------------------------------------
City | OXNARD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93036-1168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-666-9024
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 N SWALL DR UNIT 504
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90211-4725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-666-9024
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MICHAEL NEDJAT-HAIEM
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 310-666-9024
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------