Provider Demographics
NPI:1922496207
Name:HABIBI, HOMA
Entity Type:Individual
Prefix:
First Name:HOMA
Middle Name:
Last Name:HABIBI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O.BOX 9292
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95157
Mailing Address - Country:US
Mailing Address - Phone:408-828-5096
Mailing Address - Fax:
Practice Address - Street 1:19500 PRUNERIDGE AVE APT 10212
Practice Address - Street 2:
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-6755
Practice Address - Country:US
Practice Address - Phone:408-828-5096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA47103126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant