Provider Demographics
NPI:1225173479
Name:BEHZADI, NILOOFAR (DDS)
Entity Type:Individual
Prefix:DR
First Name:NILOOFAR
Middle Name:
Last Name:BEHZADI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:NILOOFAR
Other - Middle Name:
Other - Last Name:BEHZADI-SHANNON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 503
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92038-0503
Mailing Address - Country:US
Mailing Address - Phone:619-930-9811
Mailing Address - Fax:619-930-9344
Practice Address - Street 1:306 WALNUT AVE
Practice Address - Street 2:SUITE 25
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-4978
Practice Address - Country:US
Practice Address - Phone:619-930-9811
Practice Address - Fax:619-930-9344
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA462431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA954509302OtherTIN