Provider Demographics
NPI:1083743926
Name:KHODADADI, KHASHAYAR (DDS)
Entity Type:Individual
Prefix:
First Name:KHASHAYAR
Middle Name:
Last Name:KHODADADI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11900 S. AVALON BLVD.
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90061-2837
Mailing Address - Country:US
Mailing Address - Phone:323-834-0100
Mailing Address - Fax:323-834-0101
Practice Address - Street 1:11900 S. AVALON BLVD.
Practice Address - Street 2:SUITE 101
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90061-2837
Practice Address - Country:US
Practice Address - Phone:323-834-0100
Practice Address - Fax:323-834-0101
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA430261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice