Provider Demographics
NPI:1437813029
Name:REZVANI, GHOLAMREZA (DDS)
Entity Type:Individual
Prefix:
First Name:GHOLAMREZA
Middle Name:
Last Name:REZVANI
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 1:900 CROSS ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-4128
Mailing Address - Country:US
Mailing Address - Phone:650-808-0855
Mailing Address - Fax:
Practice Address - Street 1:207 N BUTTE ST
Practice Address - Street 2:
Practice Address - City:WILLOWS
Practice Address - State:CA
Practice Address - Zip Code:95988-2803
Practice Address - Country:US
Practice Address - Phone:530-934-4641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-29
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA04014177031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice