Provider Demographics
NPI:1447435250
Name:BROOKVALE FAMILY DENTISTRY
Entity type:Organization
Organization Name:BROOKVALE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FARSHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:MOFTAKHAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-274-7485
Mailing Address - Street 1:9025 WILSHIRE BLVD
Mailing Address - Street 2:STE 315
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-1831
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:39236 ARGONAUT WAY
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1306
Practice Address - Country:US
Practice Address - Phone:510-739-0701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-31
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38565122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty