Dental Board of California
Licensing details for: 16965
Name: GRACE DENTAL OF MODESTO DENTAL OFFICE OF DR. POUYAN TAQAVI
License Type: Fictitious Name Permit
Primary Status: Current - Active
Organization Classification: Corporation
License Relationships
FNP Owners
License/Registration Role: Fictitious Name Permit
Related Party Role: Owners
Name: SOROUSHIAN, VASNA
Address Not Disclosed
FNP Owners
License/Registration Role: Fictitious Name Permit
Related Party Role: Owners
Name: TAQAVI, POUYAN
Address Not Disclosed
FNP to DDS or OMS
License/Registration Role: Fictitious Name Permit
Related Party Role: Must hold an active Dental License, or Oral Maxillofacial Surgery Permit
Name: SOROUSHIAN, VASNA
License/Registration Type: Dentist License
License Number: 65124 Primary Status: Current - Active
Address :
3125 Coffee Rd # 7
MODESTO CA 95355-1768
STANISLAUS COUNTY
FNP to DDS or OMS
License/Registration Role: Fictitious Name Permit
Related Party Role: Must hold an active Dental License, or Oral Maxillofacial Surgery Permit
Name: TAQAVI, POUYAN
License/Registration Type: Dentist License
License Number: 62710 Primary Status: Current - Active
Address :
1540 N Tracy Blvd
TRACY CA 95376-2903
STANISLAUS COUNTY
