Healthcare Provider Details

I. General information

NPI: 1902985492
Provider Name (Legal Business Name): EHSAN REZVAN DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7880 WREN AVE BUILDING D SUITE 144
GILROY CA
95020-4943
US

IV. Provider business mailing address

7880 WREN AVE BUILDING D SUITE 144
GILROY CA
95020-4943
US

V. Phone/Fax

Practice location:
  • Phone: 408-842-9045
  • Fax: 408-842-7057
Mailing address:
  • Phone: 408-842-9045
  • Fax: 408-842-7057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number53479
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: