Healthcare Provider Details

I. General information

NPI: 1154834000
Provider Name (Legal Business Name): NILOOFAR DEYHIM DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2017
Last Update Date: 02/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 COFFEE RD STE E14
MODESTO CA
95355-3191
US

IV. Provider business mailing address

3550 ALDEN WAY APT 15
SAN JOSE CA
95117-1569
US

V. Phone/Fax

Practice location:
  • Phone: 209-522-9963
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: NILOOFAR DEYHIM
Title or Position: DDS
Credential: DDS
Phone: 408-608-8012