Healthcare Provider Details

I. General information

NPI: 1639299621
Provider Name (Legal Business Name): LADAN VAKILI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1036 SIR FRANCIS DRAKE BLVD
KENTFIELD CA
94904-1427
US

IV. Provider business mailing address

1036 SIR FRANCIS DRAKE BLVD
KENTFIELD CA
94904-1427
US

V. Phone/Fax

Practice location:
  • Phone: 415-454-6414
  • Fax: 415-454-6415
Mailing address:
  • Phone: 415-454-6414
  • Fax: 415-454-6415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number49019
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: