Healthcare Provider Details

I. General information

NPI: 1831782267
Provider Name (Legal Business Name): SAM BARADARAN DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2021
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16440 VANOWEN ST
VAN NUYS CA
91406-4729
US

IV. Provider business mailing address

16440 VANOWEN ST
VAN NUYS CA
91406-4729
US

V. Phone/Fax

Practice location:
  • Phone: 818-779-4900
  • Fax:
Mailing address:
  • Phone: 818-779-4900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: SAM BARADARAN
Title or Position: DDS
Credential:
Phone: 818-447-0098