Provider Demographics
NPI:1720130859
Name:VAFADAR, MAKAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MAKAN
Middle Name:
Last Name:VAFADAR
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 1:1300 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2506
Mailing Address - Country:US
Mailing Address - Phone:818-245-8410
Mailing Address - Fax:818-245-8412
Practice Address - Street 1:1300 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2506
Practice Address - Country:US
Practice Address - Phone:818-245-8410
Practice Address - Fax:310-571-3300
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA472011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB47201-01Medicaid