Healthcare Provider Details

I. General information

NPI: 1649721135
Provider Name (Legal Business Name): SHAHRYAR SEFIDPOUR DDS MSD MSME
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2016
Last Update Date: 10/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 DOUGLAS BLVD STE B
GRANITE BAY CA
95746-5908
US

IV. Provider business mailing address

4150 DOUGLAS BLVD STE B
GRANITE BAY CA
95746-5908
US

V. Phone/Fax

Practice location:
  • Phone: 916-774-6986
  • Fax: 916-774-6533
Mailing address:
  • Phone: 916-774-6986
  • Fax: 916-774-6533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number47661
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: