Provider Demographics
NPI:1619076288
Name:AZMOUDEH, KAMRAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KAMRAN
Middle Name:
Last Name:AZMOUDEH
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 1:1200 FARMERS LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-6707
Mailing Address - Country:US
Mailing Address - Phone:707-576-1416
Mailing Address - Fax:
Practice Address - Street 1:1200 FARMERS LN
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-6707
Practice Address - Country:US
Practice Address - Phone:707-576-1416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA387951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice