MEDICARE: DR. OMID NIAVARANI DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	65280	CA

General Provider Information

NPI Number	:	1104245976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OMID NIAVARANI DDS

Provider Business Mailing Address
First Line	:	17822 BEACH BLVD STE 342
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-7518
Country	:	US
Telephone Number	:	714-847-6044
Fax Number	:

Provider Business Practice Location Address
First Line	:	17822 BEACH BLVD STE 342
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-7518
Country	:	US
Telephone Number	:	714-847-6044
Fax Number	:	714-842-3145

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/09/2014
Last Update Date	:	09/24/2019

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