Healthcare Provider Details

I. General information

NPI: 1861538118
Provider Name (Legal Business Name): SIAMAK MADANI D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4155 MOORPARK AVE STE 18
SAN JOSE CA
95117-1714
US

IV. Provider business mailing address

4155 MOORPARK AVE STE 18
SAN JOSE CA
95117-1714
US

V. Phone/Fax

Practice location:
  • Phone: 408-244-7674
  • Fax: 408-246-3226
Mailing address:
  • Phone: 408-244-7674
  • Fax: 408-246-3226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number38872
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: