MEDICARE: DR. NEGAR BOLOORCHI D.D.S.

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	28774	TX
2	1223D0004X	Dental Anesthesiology	1535	CA
3	1223G0001X	General Practice Dentistry	28774	TX
4	122300000X	Dentist	57464	CA

General Provider Information

NPI Number	:	1619126943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NEGAR BOLOORCHI D.D.S.

Provider Business Mailing Address
First Line	:	2699 E CALIFORNIA BLVD
Second Line	:
City	:	SAN MARINO
State	:	CA
Zip	:	91108-1404
Country	:	US
Telephone Number	:	626-354-1440
Fax Number	:

Provider Business Practice Location Address
First Line	:	1800 SAN MIGUEL DR
Second Line	:
City	:	WALNUT CREEK
State	:	CA
Zip	:	94596-8606
Country	:	US
Telephone Number	:	925-949-8427
Fax Number	:

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

Provider Enumeration Date	:	09/10/2008
Last Update Date	:	09/12/2021

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Directions to “ DR. NEGAR BOLOORCHI D.D.S.” Practice Location

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