Healthcare Provider Details

I. General information

NPI: 1154533180
Provider Name (Legal Business Name): KOUSHAN HAIDARZADEH AZAD DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 N H ST STE P
LOMPOC CA
93436-8141
US

IV. Provider business mailing address

1009 N H ST STE P
LOMPOC CA
93436-8141
US

V. Phone/Fax

Practice location:
  • Phone: 805-242-4044
  • Fax:
Mailing address:
  • Phone: 805-242-4044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019026920
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: