Provider Demographics
NPI:1033274782
Name:DEHESTANI, FATEMEH
Entity Type:Individual
Prefix:
First Name:FATEMEH
Middle Name:
Last Name:DEHESTANI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 VALECROFT AVE
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-1444
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1397 E LOS ANGELES AVE
Practice Address - Street 2:#F
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-2866
Practice Address - Country:US
Practice Address - Phone:805-577-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49509122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist