Healthcare Provider Details

I. General information

NPI: 1528156809
Provider Name (Legal Business Name): SUDABEH Z MOAVENIAN DDS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39340 FREMONT BLVD
FREMONT CA
94538-1320
US

IV. Provider business mailing address

100 BAHAMA CT
SAN RAMON CA
94582-1403
US

V. Phone/Fax

Practice location:
  • Phone: 510-739-3889
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number38333
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: