MEDICARE: FARNOUSH FADAVI D.M.D.

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	1223E0200X	Endodontics	45855	CA

General Provider Information

NPI Number	:	1376675504
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FARNOUSH FADAVI D.M.D.

Provider Business Mailing Address
First Line	:	13001 SEAL BEACH BLVD STE 310
Second Line	:
City	:	SEAL BEACH
State	:	CA
Zip	:	90740-2757
Country	:	US
Telephone Number	:	562-431-1920
Fax Number	:	562-431-6134

Provider Business Practice Location Address
First Line	:	13001 SEAL BEACH BLVD STE 310
Second Line	:
City	:	SEAL BEACH
State	:	CA
Zip	:	90740-2757
Country	:	US
Telephone Number	:	562-431-1920
Fax Number	:	562-431-6134

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

Provider Enumeration Date	:	03/12/2007
Last Update Date	:	04/09/2019

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