Provider Demographics
NPI:1730794801
Name:EDALAT DENTAL GROUP, APC
Entity type:Organization
Organization Name:EDALAT DENTAL GROUP, APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:EDALAT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-999-9669
Mailing Address - Street 1:18450 DEARBORN ST
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-2259
Mailing Address - Country:US
Mailing Address - Phone:310-999-9669
Mailing Address - Fax:
Practice Address - Street 1:18450 DEARBORN ST
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-2259
Practice Address - Country:US
Practice Address - Phone:310-999-9669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental