Healthcare Provider Details

I. General information

NPI: 1396985818
Provider Name (Legal Business Name): SHARAREH REZAZADEH-AZAR DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHERRY AZAR

II. Dates (important events)

Enumeration Date: 02/23/2009
Last Update Date: 04/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 DORIS AVE. SUITE 519
TORONTO ON
M2N0C1
CA

IV. Provider business mailing address

15335 BRAUN CT
MOORPARK CA
93021-3216
US

V. Phone/Fax

Practice location:
  • Phone: 905-891-9372
  • Fax:
Mailing address:
  • Phone: 647-702-1777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number58069
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number58069
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: