Provider Demographics
NPI:1306988118
Name:THE SAFOURA MASSOURI PROFESSIONAL DENTAL CORP
Entity type:Organization
Organization Name:THE SAFOURA MASSOURI PROFESSIONAL DENTAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAFOURA
Authorized Official - Middle Name:
Authorized Official - Last Name:MASSOUMI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-425-9930
Mailing Address - Street 1:397 E ST
Mailing Address - Street 2:STE #A
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910
Mailing Address - Country:US
Mailing Address - Phone:619-425-9930
Mailing Address - Fax:619-425-9887
Practice Address - Street 1:397 E ST
Practice Address - Street 2:STE #A
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910
Practice Address - Country:US
Practice Address - Phone:619-425-9930
Practice Address - Fax:619-425-9887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA406771223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9226501Medicaid