Provider Demographics
NPI:1881608784
Name:ZOUFAN, KEIVAN (DDS, MDS)
Entity type:Individual
Prefix:
First Name:KEIVAN
Middle Name:
Last Name:ZOUFAN
Suffix:
Gender:M
Credentials:DDS, MDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10055 MILLER AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-3472
Mailing Address - Country:US
Mailing Address - Phone:310-592-0731
Mailing Address - Fax:
Practice Address - Street 1:10055 MILLER AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-3472
Practice Address - Country:US
Practice Address - Phone:310-592-0731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0000321223G0001X
AZ61201223G0001X
CT0097971223G0001X, 1223E0200X
CA527001223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02701531Medicaid
NY9181534OtherDORAL