Provider Demographics
NPI:1720400344
Name:FATEMEH DEHESTANI DDS, INC.
Entity Type:Organization
Organization Name:FATEMEH DEHESTANI DDS, INC.
Other - Org Name:QCI FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FATEMEH
Authorized Official - Middle Name:
Authorized Official - Last Name:DEHESTANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-379-2288
Mailing Address - Street 1:1429 E THOUSAND OAKS BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91362-2801
Mailing Address - Country:US
Mailing Address - Phone:805-379-2288
Mailing Address - Fax:805-379-2281
Practice Address - Street 1:1429 E THOUSAND OAKS BLVD
Practice Address - Street 2:STE 101
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91362-2801
Practice Address - Country:US
Practice Address - Phone:805-379-2288
Practice Address - Fax:805-379-2281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA495091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty