Provider Demographics
NPI:1982184024
Name:HOOSHMAND, PAYAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:PAYAM
Middle Name:
Last Name:HOOSHMAND
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2195 STATION VILLAGE WAY APT 1215
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-6529
Mailing Address - Country:US
Mailing Address - Phone:520-300-0645
Mailing Address - Fax:
Practice Address - Street 1:2195 STATION VILLAGE WAY APT 1215
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-6529
Practice Address - Country:US
Practice Address - Phone:520-300-0645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103091122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist