Provider Demographics
NPI:1912028002
Name:KHODAVERDIAN, NJDEH (DDS)
Entity Type:Individual
Prefix:DR
First Name:NJDEH
Middle Name:
Last Name:KHODAVERDIAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:NJDIK
Other - Middle Name:
Other - Last Name:KHODAVERDIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:610 N CENTRAL AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-1403
Mailing Address - Country:US
Mailing Address - Phone:818-547-4020
Mailing Address - Fax:818-547-4026
Practice Address - Street 1:610 N CENTRAL AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-1403
Practice Address - Country:US
Practice Address - Phone:818-547-4020
Practice Address - Fax:818-547-4026
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA493451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice