Provider Demographics
NPI:1912021924
Name:BORHANI, FARDAD (DMD)
Entity Type:Individual
Prefix:
First Name:FARDAD
Middle Name:
Last Name:BORHANI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:FARDAD
Other - Middle Name:
Other - Last Name:BORHANI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:1601 BARTON RD
Mailing Address - Street 2:APT 2510
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1601 BARTON RD
Practice Address - Street 2:APT 2510
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5306
Practice Address - Country:US
Practice Address - Phone:909-792-8079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54068122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist