Healthcare Provider Details

I. General information

NPI: 1588063838
Provider Name (Legal Business Name): YASHAR FARAHVASH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2014
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

266 N JACKSON AVE STE 1
SAN JOSE CA
95116-1606
US

IV. Provider business mailing address

2400 MOORPARK AVE STE 300
SAN JOSE CA
95128-2680
US

V. Phone/Fax

Practice location:
  • Phone: 408-975-2731
  • Fax: 408-975-2766
Mailing address:
  • Phone: 408-975-2730
  • Fax: 408-975-2764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number108596
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN1856720
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: