Provider Demographics
NPI:1245512649
Name:REZA M. BIRJANDI DDS., A PROFESSIONAL DENTAL CORPORATION
Entity type:Organization
Organization Name:REZA M. BIRJANDI DDS., A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ESBEIDY
Authorized Official - Middle Name:
Authorized Official - Last Name:LOMELI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-679-0691
Mailing Address - Street 1:28401 BRADLEY RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:SUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92586-3040
Mailing Address - Country:US
Mailing Address - Phone:951-679-0691
Mailing Address - Fax:951-679-6094
Practice Address - Street 1:28401 BRADLEY RD
Practice Address - Street 2:SUITE C
Practice Address - City:SUN CITY
Practice Address - State:CA
Practice Address - Zip Code:92586-3040
Practice Address - Country:US
Practice Address - Phone:951-679-0691
Practice Address - Fax:951-679-6094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-13
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38259122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG94101-02OtherMEDICAL