Provider Demographics
NPI:1821751611
Name:FATHI-KELLY, HOORSHAD (DDS)
Entity Type:Individual
Prefix:MRS
First Name:HOORSHAD
Middle Name:
Last Name:FATHI-KELLY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MISS
Other - First Name:HOORSHAD
Other - Middle Name:
Other - Last Name:FATHI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 102
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94551-0102
Mailing Address - Country:US
Mailing Address - Phone:858-291-9895
Mailing Address - Fax:
Practice Address - Street 1:707 PARNASSUS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2210
Practice Address - Country:US
Practice Address - Phone:415-514-3791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1070621223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics