Provider Demographics
NPI:1689718108
Name:AFSHAR, SIAMAK (DDS)
Entity Type:Individual
Prefix:DR
First Name:SIAMAK
Middle Name:
Last Name:AFSHAR
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 1:5712 LARRY DEAN ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92880-3150
Mailing Address - Country:US
Mailing Address - Phone:909-923-9724
Mailing Address - Fax:
Practice Address - Street 1:11623 CHERRY AVE
Practice Address - Street 2:SUITE B-2
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92337-1212
Practice Address - Country:US
Practice Address - Phone:909-355-1485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA507171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice