Provider Demographics
NPI:1649495987
Name:JANFAZA, EDMOND
Entity type:Individual
Prefix:
First Name:EDMOND
Middle Name:
Last Name:JANFAZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 E SLAUSON AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-2926
Mailing Address - Country:US
Mailing Address - Phone:323-589-3391
Mailing Address - Fax:323-589-3728
Practice Address - Street 1:2675 E SLAUSON AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-2926
Practice Address - Country:US
Practice Address - Phone:323-589-3391
Practice Address - Fax:323-589-3728
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34719122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist