Provider Demographics
NPI:1851469985
Name:KHERADYAR, HAMID COHEN (DDS)
Entity Type:Individual
Prefix:
First Name:HAMID
Middle Name:COHEN
Last Name:KHERADYAR
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 1:138 S GAFFEY ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-2430
Mailing Address - Country:US
Mailing Address - Phone:310-514-9100
Mailing Address - Fax:310-514-9119
Practice Address - Street 1:138 S GAFFEY ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-2430
Practice Address - Country:US
Practice Address - Phone:310-514-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD39023OtherDENTI-CAL TREATING PROVID
CAG-898601OtherDENTI-CAL BILLING PROVIDE