=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295927275
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOHEIL KHODADADI DMD, DDS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2007
-----------------------------------------------------
Last Update Date | 08/14/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 E FLORIDA AVE SPACE #A20
-----------------------------------------------------
City | HEMET
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92544-8640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-765-5544
-----------------------------------------------------
Fax | 951-765-5511
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1300 E FLORIDA AVE SPACE #A20
-----------------------------------------------------
City | HEMET
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92544-8640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-765-5544
-----------------------------------------------------
Fax | 951-765-5511
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | DR. SOHEIL KHODADADI
-----------------------------------------------------
Credential | DMD, DDS
-----------------------------------------------------
Telephone | 951-765-5544
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 39024
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------