Healthcare Provider Details

I. General information

NPI: 1003106949
Provider Name (Legal Business Name): JOEY PEDRAM D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2011
Last Update Date: 04/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1188 ROADRUNNER WAY
SIMI VALLEY CA
93065-3158
US

IV. Provider business mailing address

1188 ROADRUNNER WAY
SIMI VALLEY CA
93065-3158
US

V. Phone/Fax

Practice location:
  • Phone: 805-526-1188
  • Fax:
Mailing address:
  • Phone: 805-526-1188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number60095
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: