Provider Demographics
NPI:1205380052
Name:TEHRANI, PEGAH
Entity Type:Individual
Prefix:
First Name:PEGAH
Middle Name:
Last Name:TEHRANI
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 1:22300 MOBILE ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91303-2426
Mailing Address - Country:US
Mailing Address - Phone:949-300-8054
Mailing Address - Fax:
Practice Address - Street 1:1037 E PALMDALE BLVD
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-4745
Practice Address - Country:US
Practice Address - Phone:661-272-9181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100682122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist