Provider Demographics
NPI:1760796023
Name:EDALAT, HOSSEIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:HOSSEIN
Middle Name:
Last Name:EDALAT
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 1:130 AVENIDA CABRILLO STE B
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-5509
Mailing Address - Country:US
Mailing Address - Phone:949-409-4080
Mailing Address - Fax:
Practice Address - Street 1:130 AVENIDA CABRILLO STE B
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-5509
Practice Address - Country:US
Practice Address - Phone:949-409-4080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57231122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist