Provider Demographics
NPI:1326260597
Name:HOMAYUN, MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HOMAYUN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4640 ADMIRALTY WAY
Mailing Address - Street 2:SUITE 1001
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6621
Mailing Address - Country:US
Mailing Address - Phone:310-821-2611
Mailing Address - Fax:
Practice Address - Street 1:4640 ADMIRALTY WAY
Practice Address - Street 2:SUITE 1001
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6621
Practice Address - Country:US
Practice Address - Phone:310-821-2611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA378381223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics