Healthcare Provider Details

I. General information

NPI: 1114124989
Provider Name (Legal Business Name): BAHAREH FATHI D.D.S., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4366 TUJUNGA AVE
STUDIO CITY CA
91604-2751
US

IV. Provider business mailing address

1045 PASO ALTO DR
PASADENA CA
91105-1134
US

V. Phone/Fax

Practice location:
  • Phone: 818-985-5462
  • Fax:
Mailing address:
  • Phone: 818-207-1490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number53905
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: