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General NPI Number Information
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NPI Number | 1114780731
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Entity Type | Individual
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Provider Name | BAHMAN DERAKHSHAN DMD
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Gender | Male
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Dates
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Enumeration Date | 02/05/2024
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Last Update Date | 11/13/2024
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Provider Practice Location Address
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Address Line | 179 N TUSTIN ST
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City | ORANGE
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State | CA
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Zip | 92867-7716
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Country | US
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Telephone | 949-346-6655
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Fax |
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Provider Business Mailing Address
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Address Line | 179 N TUSTIN ST
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City | ORANGE
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State | CA
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Zip | 92867-7716
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Country | US
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Telephone | 493-466-6559
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DDS110875
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN10000579
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License Number State | MA
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