MEDICARE: PAYAM PEZESHKIAN D.D.S. INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	51987	CA

General Provider Information

NPI Number	:	1609076116
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAYAM PEZESHKIAN D.D.S. INC.

Provider Business Mailing Address
First Line	:	1161 HIDDEN VALLEY PKWY
Second Line	:	SUITE 106
City	:	NORCO
State	:	CA
Zip	:	92860-3916
Country	:	US
Telephone Number	:	949-351-7607
Fax Number	:

Provider Business Practice Location Address
First Line	:	1161 HIDDEN VALLEY PKWY
Second Line	:	SUITE 106
City	:	NORCO
State	:	CA
Zip	:	92860-3916
Country	:	US
Telephone Number	:	949-351-7607
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PAYAM PEZESHKIAN PEZESHKIAN
Credential	:
Telephone Number	:	949-351-7607

Provider Enumeration Date	:	07/23/2007
Last Update Date	:	07/23/2007

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