Basic Information
Provider Information
NPI: 1073602157
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MATINFAR
FirstName: FARIBA
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: NONE
OtherFirstName: NONE
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential: D.D.S.
OtherLastNameType: 2
Mailing Information
Address1: PO BOX 11021
Address2:  
City: BEVERLY HILLS
State: CA
PostalCode: 902134521
CountryCode: US
TelephoneNumber: 3235285153
FaxNumber:  
Practice Location
Address1: 550 E DEL AMO BLVD
Address2:  
City: CARSON
State: CA
PostalCode: 907463314
CountryCode: US
TelephoneNumber: 3105155672
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/12/2006
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223P0300X43547CAY Dental ProvidersDentistPeriodontics

No ID Information.


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