Provider Demographics
NPI:1912736588
Name:KOUSHAN H. AZAD PROFESSIONAL DENTAL CORPORATION
Entity type:Organization
Organization Name:KOUSHAN H. AZAD PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KOUSHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AZAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-242-4044
Mailing Address - Street 1:272 RESERVATION RD
Mailing Address - Street 2:
Mailing Address - City:MARINA
Mailing Address - State:CA
Mailing Address - Zip Code:93933-3178
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:272 RESERVATION RD
Practice Address - Street 2:
Practice Address - City:MARINA
Practice Address - State:CA
Practice Address - Zip Code:93933-3178
Practice Address - Country:US
Practice Address - Phone:805-242-4044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty