Provider Demographics
NPI:1700895166
Name:FARAJZADEH, EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:FARAJZADEH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13983 MANGO DR STE 106
Mailing Address - Street 2:
Mailing Address - City:DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014-3146
Mailing Address - Country:US
Mailing Address - Phone:858-792-6662
Mailing Address - Fax:858-792-0536
Practice Address - Street 1:13983 MANGO DR STE 106
Practice Address - Street 2:
Practice Address - City:DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92014-3146
Practice Address - Country:US
Practice Address - Phone:858-792-6662
Practice Address - Fax:858-792-0536
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33031122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No122300000XDental ProvidersDentist