Healthcare Provider Details

I. General information

NPI: 1548386279
Provider Name (Legal Business Name): REZA KHAZAIE,DDS,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 06/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 WILLOW PASS RD
CONCORD CA
94520-5218
US

IV. Provider business mailing address

1255 WILLOW PASS RD
CONCORD CA
94520-5218
US

V. Phone/Fax

Practice location:
  • Phone: 925-680-4444
  • Fax: 925-680-4443
Mailing address:
  • Phone: 925-680-4444
  • Fax: 925-680-4443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number41035
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number54286
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number54123
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. REZA KHAZAIE
Title or Position: OWNER
Credential: DDS
Phone: 925-680-4444