Healthcare Provider Details

I. General information

NPI: 1346325511
Provider Name (Legal Business Name): ROZITA BAHADORI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2990 W GRANT LINE RD
TRACY CA
95304-7901
US

IV. Provider business mailing address

726 BOWEN CT
SAN RAMON CA
94582-5699
US

V. Phone/Fax

Practice location:
  • Phone: 209-830-7797
  • Fax: 209-830-6842
Mailing address:
  • Phone: 925-829-3006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number52242
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: