Provider Demographics
NPI:1093995482
Name:FAHANDEZA, MAHSHID (DMD)
Entity Type:Individual
Prefix:
First Name:MAHSHID
Middle Name:
Last Name:FAHANDEZA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:646 W MAIN STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243
Mailing Address - Country:US
Mailing Address - Phone:760-339-9992
Mailing Address - Fax:760-353-3635
Practice Address - Street 1:646 W MAIN STREET
Practice Address - Street 2:SUITE A
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243
Practice Address - Country:US
Practice Address - Phone:760-339-9992
Practice Address - Fax:760-353-3635
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56288122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist