Provider Demographics
NPI:1891881579
Name:FARAHBOD, KAWEH (DDS)
Entity Type:Individual
Prefix:
First Name:KAWEH
Middle Name:
Last Name:FARAHBOD
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 1:7689 WESMINSTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WESMISTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-3921
Mailing Address - Country:US
Mailing Address - Phone:714-893-1356
Mailing Address - Fax:714-894-9387
Practice Address - Street 1:7689 WESMINSTER BLVD
Practice Address - Street 2:
Practice Address - City:WESMISTER
Practice Address - State:CA
Practice Address - Zip Code:92683-3921
Practice Address - Country:US
Practice Address - Phone:714-893-1356
Practice Address - Fax:714-894-9387
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA417241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA685422OtherUNITED CONCORDIA ID #
CAB41724-1Medicaid