MEDICARE: BAHAREH DADRESANFAR DDS, ENDODONTIST

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	DE61321114	WA

General Provider Information

NPI Number	:	1699497743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BAHAREH DADRESANFAR DDS, ENDODONTIST

Provider Business Mailing Address
First Line	:	4458 VIA PASEAR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92122-1506
Country	:	US
Telephone Number	:	360-448-5503
Fax Number	:

Provider Business Practice Location Address
First Line	:	4458 VIA PASEAR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92122-1506
Country	:	US
Telephone Number	:	360-448-5503
Fax Number	:

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

Provider Enumeration Date	:	09/15/2022
Last Update Date	:	09/15/2022

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