Healthcare Provider Details

I. General information

NPI: 1740663848
Provider Name (Legal Business Name): AZADEH REZAIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11635 SOUTH ST
ARTESIA CA
90701-6628
US

IV. Provider business mailing address

11635 SOUTH ST
ARTESIA CA
90701-6628
US

V. Phone/Fax

Practice location:
  • Phone: 562-924-4401
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN21393
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number109618
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: