Provider Demographics
NPI:1780637835
Name:BAVAFA, HOSEIN S (DDS)
Entity Type:Individual
Prefix:DR
First Name:HOSEIN
Middle Name:S
Last Name:BAVAFA
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 1:2620 ASHBY AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705
Mailing Address - Country:US
Mailing Address - Phone:510-883-9373
Mailing Address - Fax:510-883-9372
Practice Address - Street 1:2620 ASHBY AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705
Practice Address - Country:US
Practice Address - Phone:510-883-9373
Practice Address - Fax:510-883-9372
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44806122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist