Healthcare Provider Details

I. General information

NPI: 1881049179
Provider Name (Legal Business Name): SASCHA EALIA ZANDEVAKILI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4125 SORRENTO VALLEY BLVD STE D
SAN DIEGO CA
92121-1423
US

IV. Provider business mailing address

EMORY CLINIC BUILDING B STE 2300 1365 CLIFTON ROAD, NE
ATLANTA GA
30322-1013
US

V. Phone/Fax

Practice location:
  • Phone: 858-997-2701
  • Fax:
Mailing address:
  • Phone: 404-778-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number102544
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: