Provider Demographics
NPI:1376715771
Name:DELDENTAL GROUP
Entity Type:Organization
Organization Name:DELDENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAHRZAD
Authorized Official - Middle Name:Z
Authorized Official - Last Name:FATTAHI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-822-8118
Mailing Address - Street 1:8035 W MANCHESTER AVE STE B
Mailing Address - Street 2:
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-7985
Mailing Address - Country:US
Mailing Address - Phone:310-822-8118
Mailing Address - Fax:310-821-9276
Practice Address - Street 1:8035 W MANCHESTER AVE STE B
Practice Address - Street 2:
Practice Address - City:PLAYA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90293-7985
Practice Address - Country:US
Practice Address - Phone:310-822-8118
Practice Address - Fax:310-821-9276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA419131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1447320338Medicaid