Provider Demographics
NPI:1689076994
Name:KHADEM, ROXANNA MARIE (DMD)
Entity Type:Individual
Prefix:
First Name:ROXANNA
Middle Name:MARIE
Last Name:KHADEM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2252 WATERMARKE PL
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-7693
Mailing Address - Country:US
Mailing Address - Phone:949-525-2076
Mailing Address - Fax:
Practice Address - Street 1:2252 WATERMARKE PL
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-7693
Practice Address - Country:US
Practice Address - Phone:949-525-2076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64058122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist