Healthcare Provider Details

I. General information

NPI: 1427229848
Provider Name (Legal Business Name): HOSEIN BAVAFA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2008
Last Update Date: 03/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 ASHBY AVE SUITE 201
BERKELEY CA
94705
US

IV. Provider business mailing address

2620 ASHBY AVE SUITE 201
BERKELEY CA
94705
US

V. Phone/Fax

Practice location:
  • Phone: 510-883-9373
  • Fax: 510-883-9372
Mailing address:
  • Phone: 510-883-9373
  • Fax: 510-883-9372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number44806
License Number StateCA

VIII. Authorized Official

Name: DR. HOSEIN S BAVAFA
Title or Position: DENTIST
Credential: DDS
Phone: 510-883-9373