Provider Demographics
NPI:1548730450
Name:MASTOUR & FARD DENTAL CORP
Entity type:Organization
Organization Name:MASTOUR & FARD DENTAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PEDRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTOUR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-804-0414
Mailing Address - Street 1:5620 SAWTELLE BLVD
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-5508
Mailing Address - Country:US
Mailing Address - Phone:310-390-6212
Mailing Address - Fax:310-390-6215
Practice Address - Street 1:587 N. VENTU PARK ROAD.
Practice Address - Street 2:SUITE C
Practice Address - City:NEWBERRY PARK
Practice Address - State:CA
Practice Address - Zip Code:91320
Practice Address - Country:US
Practice Address - Phone:805-499-1253
Practice Address - Fax:805-499-1453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-04
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization