Provider Demographics
NPI:1770810343
Name:SEPARZADEH, RAPHAEL (DDS, MSD)
Entity type:Individual
Prefix:DR
First Name:RAPHAEL
Middle Name:
Last Name:SEPARZADEH
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5543 AURA AVE
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3005
Mailing Address - Country:US
Mailing Address - Phone:818-523-6337
Mailing Address - Fax:
Practice Address - Street 1:5543 AURA AVE
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3005
Practice Address - Country:US
Practice Address - Phone:818-523-6337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-03
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA562031223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics