Provider Demographics
NPI:1740278662
Name:VATANKHAHAN, OMID (DDS)
Entity type:Individual
Prefix:
First Name:OMID
Middle Name:
Last Name:VATANKHAHAN
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 1:301 1/2 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-4852
Mailing Address - Country:US
Mailing Address - Phone:714-547-6600
Mailing Address - Fax:714-547-6610
Practice Address - Street 1:301 1/2 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4852
Practice Address - Country:US
Practice Address - Phone:714-547-6600
Practice Address - Fax:714-547-6610
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA492591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9279901Medicaid