MEDICARE: MARAL RANJBAR AGHDAM

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	122300000X	Dentist	102522	CA

General Provider Information

NPI Number	:	1144713173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARAL RANJBAR AGHDAM

Provider Business Mailing Address
First Line	:	3205-1151 WEST GEORGIA ST
Second Line	:
City	:	VANCOUVER
State	:	BRITISH COLUMBIA
Zip	:	V6E4E6
Country	:	CA
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1821 N LONG BEACH BLVD
Second Line	:
City	:	COMPTON
State	:	CA
Zip	:	90221
Country	:	US
Telephone Number	:	714-262-2708
Fax Number	:

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

Provider Enumeration Date	:	06/13/2018
Last Update Date	:	06/14/2018

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