MEDICARE: SOROUR D.M.D, PC

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

General Provider Information

NPI Number	:	1750736591
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOROUR D.M.D, PC

Provider Business Mailing Address
First Line	:	1701 N MAIN ST
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92706-2745
Country	:	US
Telephone Number	:	714-795-2177
Fax Number	:

Provider Business Practice Location Address
First Line	:	1701 N MAIN ST
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92706-2745
Country	:	US
Telephone Number	:	714-795-2177
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	SELVANA SOROUR
Credential	:	D.M.D
Telephone Number	:	310-795-3363

Provider Enumeration Date	:	04/29/2016
Last Update Date	:	04/29/2016

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