MEDICARE: PERIODONTICS, ORAL AND FACIAL SURGICAL SPECIALTIES

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	1223P0300X	Periodontics
2	261QD0000X	Dental Clinic/Center
3	261QS0112X	Oral and Maxillofacial Surgery Clinic/Center
4	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

General Provider Information

NPI Number	:	1386234284
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERIODONTICS, ORAL AND FACIAL SURGICAL SPECIALTIES

Provider Business Mailing Address
First Line	:	29829 SANTA MARGARITA PKWY STE 300
Second Line	:
City	:	RANCHO SANTA MARGARITA
State	:	CA
Zip	:	92688-3623
Country	:	US
Telephone Number	:	949-888-0332
Fax Number	:	949-888-0400

Provider Business Practice Location Address
First Line	:	29829 SANTA MARGARITA PKWY STE 300
Second Line	:
City	:	RANCHO SANTA MARGARITA
State	:	CA
Zip	:	92688-3623
Country	:	US
Telephone Number	:	949-888-0332
Fax Number	:	949-888-0400

Authorized Official
Title or Position	:	OWNER
Name	:	DR. REZA BOLOURIAN
Credential	:	MD
Telephone Number	:	949-888-0332

Provider Enumeration Date	:	01/25/2021
Last Update Date	:	01/25/2021

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