Healthcare Provider Details

I. General information

NPI: 1770810343
Provider Name (Legal Business Name): RAPHAEL SEPARZADEH DDS, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2009
Last Update Date: 04/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5543 AURA AVE
TARZANA CA
91356-3005
US

IV. Provider business mailing address

5543 AURA AVE
TARZANA CA
91356-3005
US

V. Phone/Fax

Practice location:
  • Phone: 818-523-6337
  • Fax:
Mailing address:
  • Phone: 818-523-6337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number56203
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: