Healthcare Provider Details

I. General information

NPI: 1194038059
Provider Name (Legal Business Name): PAYAM BEHRADNIA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2010
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4757 HOEN AVE
SANTA ROSA CA
95405-7862
US

IV. Provider business mailing address

4757 HOEN AVE
SANTA ROSA CA
95405-7862
US

V. Phone/Fax

Practice location:
  • Phone: 310-478-3711
  • Fax: 707-575-5122
Mailing address:
  • Phone: 310-598-0409
  • Fax: 707-575-5122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number60893
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: