Provider Demographics
NPI:1386042166
Name:MAZAHERI-SICHANI, AFSANEH
Entity Type:Individual
Prefix:
First Name:AFSANEH
Middle Name:
Last Name:MAZAHERI-SICHANI
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 1:777 TRUMAN ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340-3382
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:777 TURMAN ST.
Practice Address - Street 2:SUITE 107
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340
Practice Address - Country:US
Practice Address - Phone:703-244-3577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-11
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401414582122300000X
CA64212122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist