Provider Demographics
NPI:1295927275
Name:SOHEIL KHODADADI DMD, DDS, INC.
Entity type:Organization
Organization Name:SOHEIL KHODADADI DMD, DDS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SOHEIL
Authorized Official - Middle Name:
Authorized Official - Last Name:KHODADADI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, DDS
Authorized Official - Phone:951-765-5544
Mailing Address - Street 1:1300 E FLORIDA AVE
Mailing Address - Street 2:SPACE #A20
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92544-8640
Mailing Address - Country:US
Mailing Address - Phone:951-765-5544
Mailing Address - Fax:951-765-5511
Practice Address - Street 1:1300 E FLORIDA AVE
Practice Address - Street 2:SPACE #A20
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92544-8640
Practice Address - Country:US
Practice Address - Phone:951-765-5544
Practice Address - Fax:951-765-5511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1710042478OtherNPI NUMBER