Provider Demographics
NPI:1649721135
Name:SEFIDPOUR, SHAHRYAR (DDS MSD MSME)
Entity type:Individual
Prefix:DR
First Name:SHAHRYAR
Middle Name:
Last Name:SEFIDPOUR
Suffix:
Gender:M
Credentials:DDS MSD MSME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 DOUGLAS BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-5908
Mailing Address - Country:US
Mailing Address - Phone:916-774-6986
Mailing Address - Fax:916-774-6533
Practice Address - Street 1:4150 DOUGLAS BLVD STE B
Practice Address - Street 2:
Practice Address - City:GRANITE BAY
Practice Address - State:CA
Practice Address - Zip Code:95746-5908
Practice Address - Country:US
Practice Address - Phone:916-774-6986
Practice Address - Fax:916-774-6533
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA476611223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics