Provider Demographics
NPI:1801262290
Name:DERAKHSHANI, NEGAR
Entity type:Individual
Prefix:
First Name:NEGAR
Middle Name:
Last Name:DERAKHSHANI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6082 EDINGER AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-3264
Mailing Address - Country:US
Mailing Address - Phone:714-846-2827
Mailing Address - Fax:714-846-4311
Practice Address - Street 1:6082 EDINGER AVE
Practice Address - Street 2:SUITE B
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-3264
Practice Address - Country:US
Practice Address - Phone:714-846-2827
Practice Address - Fax:714-846-4311
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46045122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1689886814OtherSTATE