=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972840965
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OKHOVAT PROFESSIONAL DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2013
-----------------------------------------------------
Last Update Date | 03/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2110 PROFESSIONAL DR STE 115
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95661-3778
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-783-5600
-----------------------------------------------------
Fax | 916-783-5614
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2110 PROFESSIONAL DR STE 115
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95661-3778
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-783-5600
-----------------------------------------------------
Fax | 916-783-5614
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SIAMAK OKHOVAT
-----------------------------------------------------
Credential | DDS, PHD
-----------------------------------------------------
Telephone | 916-783-5600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------