Provider Demographics
NPI:1801213475
Name:GOSHAYESHI, BAHAREH (DDS)
Entity Type:Individual
Prefix:
First Name:BAHAREH
Middle Name:
Last Name:GOSHAYESHI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3221 CARTER AVE UNIT 367
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-4963
Mailing Address - Country:US
Mailing Address - Phone:310-706-8566
Mailing Address - Fax:
Practice Address - Street 1:3221 CARTER AVE UNIT 367
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-4963
Practice Address - Country:US
Practice Address - Phone:310-706-8566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-20
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1023931223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Yes1223G0001XDental ProvidersDentistGeneral Practice