Provider Demographics
NPI:1508313693
Name:DEJAKAM, AREZOU
Entity Type:Individual
Prefix:
First Name:AREZOU
Middle Name:
Last Name:DEJAKAM
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 1:3700 S PLAZA DR
Mailing Address - Street 2:LPH7
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-7434
Mailing Address - Country:US
Mailing Address - Phone:949-690-1321
Mailing Address - Fax:
Practice Address - Street 1:3700 S PLAZA DR
Practice Address - Street 2:LPH7
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-7434
Practice Address - Country:US
Practice Address - Phone:949-690-1321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22829124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist