Healthcare Provider Details

I. General information

NPI: 1427751650
Provider Name (Legal Business Name): KIMYA KHODAMARDI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2051 JOHN JONES RD
DAVIS CA
95616-9701
US

IV. Provider business mailing address

901 SUNVALLEY BLVD STE 110
CONCORD CA
94520-5816
US

V. Phone/Fax

Practice location:
  • Phone: 866-268-4489
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS109818
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: