Healthcare Provider Details

I. General information

NPI: 1396312997
Provider Name (Legal Business Name): AZADEH KHAJAVI DMD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16516 BERNARDO CENTER DR STE 210
SAN DIEGO CA
92128-2551
US

IV. Provider business mailing address

16516 BERNARDO CENTER DR STE 210
SAN DIEGO CA
92128-2551
US

V. Phone/Fax

Practice location:
  • Phone: 858-779-9292
  • Fax:
Mailing address:
  • Phone: 858-779-9292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateNULL

VIII. Authorized Official

Name: ESTHER LOPEZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 858-779-9292