Provider Demographics
NPI:1558760926
Name:GHAFFARZADEGAN, BAHARAK (DDS)
Entity Type:Individual
Prefix:
First Name:BAHARAK
Middle Name:
Last Name:GHAFFARZADEGAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4346 MATILIJA AVE APT 107
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-3602
Mailing Address - Country:US
Mailing Address - Phone:818-468-6458
Mailing Address - Fax:
Practice Address - Street 1:4346 MATILIJA AVE #107
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423
Practice Address - Country:US
Practice Address - Phone:818-468-6458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-21
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63623122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist