Provider Demographics
NPI:1235801184
Name:HAMIDIFARD, SHERRY
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:
Last Name:HAMIDIFARD
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 1:727 BREEZE HILL RD APT 335
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-4331
Mailing Address - Country:US
Mailing Address - Phone:713-478-8993
Mailing Address - Fax:
Practice Address - Street 1:2345 S MELROSE DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-8788
Practice Address - Country:US
Practice Address - Phone:760-803-1067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-29
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106919122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist