MEDICARE: PREMIER DENTAL IMPLANT CENTER

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	45970	CA

General Provider Information

NPI Number	:	1841673696
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER DENTAL IMPLANT CENTER

Provider Business Mailing Address
First Line	:	25260 LA PAZ RD
Second Line	:	SUITE I
City	:	LAGUNA HILLS
State	:	CA
Zip	:	92653-5132
Country	:	US
Telephone Number	:	949-831-8100
Fax Number	:	949-831-8100

Provider Business Practice Location Address
First Line	:	25260 LA PAZ RD
Second Line	:	SUITE I
City	:	LAGUNA HILLS
State	:	CA
Zip	:	92653-5132
Country	:	US
Telephone Number	:	949-831-8100
Fax Number	:	949-831-8100

Authorized Official
Title or Position	:	OWNER
Name	:	DR. FARSHAD SAGHATCHI
Credential	:	DDS
Telephone Number	:	949-831-8100

Provider Enumeration Date	:	06/29/2015
Last Update Date	:	06/29/2015

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