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
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0300X | 43547 | CA | Y |   | Dental Providers | Dentist | Periodontics |
No ID Information.