Provider Demographics
NPI:1194161281
Name:ETEMADIEH DENTAL CORP.
Entity type:Organization
Organization Name:ETEMADIEH DENTAL CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALI-REZA
Authorized Official - Middle Name:
Authorized Official - Last Name:ETEMADIEH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-554-9931
Mailing Address - Street 1:665 N TUSTIN ST STE W
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-7148
Mailing Address - Country:US
Mailing Address - Phone:714-628-9910
Mailing Address - Fax:714-628-9930
Practice Address - Street 1:665 N TUSTIN ST STE W
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-7148
Practice Address - Country:US
Practice Address - Phone:714-628-9910
Practice Address - Fax:714-628-9930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61311122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty