Provider Demographics
NPI:1689863987
Name:REZA M BIRJANDI DDS A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:REZA M BIRJANDI DDS A PROFESSIONAL CORPORATION
Other - Org Name:CROSSROADS FAMILY DENTAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:REZA
Authorized Official - Middle Name:MOHAMMAD
Authorized Official - Last Name:BIRJANDI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:951-657-2222
Mailing Address - Street 1:1675 N PERRIS BLVD
Mailing Address - Street 2:SUITE A1
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571
Mailing Address - Country:US
Mailing Address - Phone:951-657-2222
Mailing Address - Fax:951-657-3582
Practice Address - Street 1:1675 N PERRIS BLVD
Practice Address - Street 2:SUITE A1
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571
Practice Address - Country:US
Practice Address - Phone:951-657-2222
Practice Address - Fax:951-657-3582
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RESA M BIRJANDI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-23
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38259122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9410102OtherMEDI CAL