Healthcare Provider Details

I. General information

NPI: 1427159748
Provider Name (Legal Business Name): CAMERON HEYDARI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 08/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 E AVENUE I MAIN FLOOR , CLINIC #17
LANCASTER CA
93535-1916
US

IV. Provider business mailing address

26339 W PLATA LN
CALABASAS CA
91302-2612
US

V. Phone/Fax

Practice location:
  • Phone: 661-471-4133
  • Fax:
Mailing address:
  • Phone: 818-200-6114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number0401410833
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number54371
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: