Healthcare Provider Details

I. General information

NPI: 1245289107
Provider Name (Legal Business Name): SOUDABEH SHARAFI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 10/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12750 CARMEL COUNTRY RD STE 215 SUITE # 215
SAN DIEGO CA
92130-2172
US

IV. Provider business mailing address

12750 CARMEL COUNTRY RD STE 215 SUITE # 215
SAN DIEGO CA
92130-2172
US

V. Phone/Fax

Practice location:
  • Phone: 858-259-1400
  • Fax: 858-259-1401
Mailing address:
  • Phone: 858-259-1400
  • Fax: 858-259-1401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number52929
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: