Provider Demographics
NPI:1619494739
Name:AVEDIAN SANGEBARANI, TADEH (DMD)
Entity Type:Individual
Prefix:DR
First Name:TADEH
Middle Name:
Last Name:AVEDIAN SANGEBARANI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11034 NASSAU AVE
Mailing Address - Street 2:
Mailing Address - City:SUNLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91040-2124
Mailing Address - Country:US
Mailing Address - Phone:818-433-9865
Mailing Address - Fax:
Practice Address - Street 1:290 E VERDUGO AVE STE 208
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502-1342
Practice Address - Country:US
Practice Address - Phone:818-566-8859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-29
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1018711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice