Provider Demographics
NPI:1235536129
Name:GANJI, DELARAM
Entity Type:Individual
Prefix:
First Name:DELARAM
Middle Name:
Last Name:GANJI
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 1:5636 MATILIJA AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY GLEN
Mailing Address - State:CA
Mailing Address - Zip Code:91401-4718
Mailing Address - Country:US
Mailing Address - Phone:310-430-6974
Mailing Address - Fax:
Practice Address - Street 1:5636 MATILIJA AVE
Practice Address - Street 2:
Practice Address - City:VALLEY GLEN
Practice Address - State:CA
Practice Address - Zip Code:91401-4718
Practice Address - Country:US
Practice Address - Phone:310-430-6974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28115124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist