Provider Demographics
NPI:1982814406
Name:KHAZAIE, REZA (DDS)
Entity Type:Individual
Prefix:
First Name:REZA
Middle Name:
Last Name:KHAZAIE
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 1:1700 BOTELHO DR APT 323
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-8572
Mailing Address - Country:US
Mailing Address - Phone:310-477-0908
Mailing Address - Fax:
Practice Address - Street 1:1700 BOTELHO DR APT 323
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-8572
Practice Address - Country:US
Practice Address - Phone:310-477-0908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA545911223G0001X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223G0001XDental ProvidersDentistGeneral Practice
Not Answered1223P0700XDental ProvidersDentistProsthodontics