Provider Demographics
NPI:1003120148
Name:ELMIRA KHODAPANAH DDS INC
Entity Type:Organization
Organization Name:ELMIRA KHODAPANAH DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELMIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHODAPANAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-245-2426
Mailing Address - Street 1:12079 WORLD TRADE DR UNIT 4
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-4393
Mailing Address - Country:US
Mailing Address - Phone:858-485-8855
Mailing Address - Fax:858-487-0531
Practice Address - Street 1:2333 CAMINO DEL RIO S STE 140
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3607
Practice Address - Country:US
Practice Address - Phone:619-574-1810
Practice Address - Fax:619-574-1326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-30
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA439891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty