Provider Demographics
NPI:1508945585
Name:SADRIEH, FATEMEH S (DDS)
Entity Type:Individual
Prefix:DR
First Name:FATEMEH
Middle Name:S
Last Name:SADRIEH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1029 GLENHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-2204
Mailing Address - Country:US
Mailing Address - Phone:818-986-3461
Mailing Address - Fax:818-986-9582
Practice Address - Street 1:4910 VAN NUYS BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1782
Practice Address - Country:US
Practice Address - Phone:818-986-3461
Practice Address - Fax:818-986-9582
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA333621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB33362-01Medicaid
CA33362OtherSTATE LICENSE #