MEDICARE: MR. SEYED REZA IZADI DEHKORDI DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	43172	CA

General Provider Information

NPI Number	:	1457426777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SEYED REZA IZADI DEHKORDI DDS

Provider Business Mailing Address
First Line	:	22982 EL TORO RD
Second Line	:	STE 100
City	:	LAKE FOREST
State	:	CA
Zip	:	92630-4961
Country	:	US
Telephone Number	:	949-305-0202
Fax Number	:	949-305-0203

Provider Business Practice Location Address
First Line	:	22982 EL TORO RD
Second Line	:	STE 100
City	:	LAKE FOREST
State	:	CA
Zip	:	92630-4961
Country	:	US
Telephone Number	:	949-305-0202
Fax Number	:	949-305-0203

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/21/2006
Last Update Date	:	08/01/2013

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