Basic Information
| Provider Information | |||||||||
| NPI: | 1639120041 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOSEPH A FOROOSH DENTAL CORP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DESERT DENTAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 12640 HESPERIA RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923957753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602413336 | ||||||||
| FaxNumber: | 7602437247 | ||||||||
| Practice Location | |||||||||
| Address1: | 12640 HESPERIA RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923957753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602413336 | ||||||||
| FaxNumber: | 7602437247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FOROOSH | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7602413336 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DMD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | X | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 1223S0112X | X | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223E0200X | X | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Endodontics | 1223P0300X | X | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Periodontics |
ID Information
| ID | Type | State | Issuer | Description | G91708-01 | 01 | CA | DENTI-CAL | OTHER | 62057 | 01 | CA | SAFEGUARD DHMO | OTHER | 784059 | 01 | CA | UNITED CONCORDIA | OTHER | D163173 | 01 | CA | CIGNA DHMO | OTHER |