Healthcare Provider Details

I. General information

NPI: 1174681001
Provider Name (Legal Business Name): HAMID KHERADMANDNIA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7424 JACKSON DR SUITE 9
SAN DIEGO CA
92119-2324
US

IV. Provider business mailing address

7424 JACKSON DR. SUITE 9
SAN DIEGO CA
92119
US

V. Phone/Fax

Practice location:
  • Phone: 619-461-9494
  • Fax: 619-461-9496
Mailing address:
  • Phone: 619-461-9494
  • Fax: 619-461-9496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number50620
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: