Provider Demographics
NPI:1720642317
Name:KHOOSHAB PATISH-PREOBRAZHENSKAYA DENTAL CORPORATION
Entity type:Organization
Organization Name:KHOOSHAB PATISH-PREOBRAZHENSKAYA DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALLA
Authorized Official - Middle Name:
Authorized Official - Last Name:PATISH-PROBRAZHENSKAYA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:424-384-9444
Mailing Address - Street 1:815 COLLEGE BLVD STE 106
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92057-6261
Mailing Address - Country:US
Mailing Address - Phone:760-306-4466
Mailing Address - Fax:760-239-0105
Practice Address - Street 1:815 COLLEGE BLVD STE 106
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92057-6261
Practice Address - Country:US
Practice Address - Phone:760-306-4466
Practice Address - Fax:760-239-0105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-29
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty