Provider Demographics
NPI:1629181854
Name:GHAFFARI, HOOSHANG (DENTIST)
Entity Type:Individual
Prefix:
First Name:HOOSHANG
Middle Name:
Last Name:GHAFFARI
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17318 VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316
Mailing Address - Country:US
Mailing Address - Phone:818-788-9292
Mailing Address - Fax:818-788-5238
Practice Address - Street 1:17318 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316
Practice Address - Country:US
Practice Address - Phone:818-788-9292
Practice Address - Fax:818-788-5238
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30523122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB30523BMedicaid