Provider Demographics
NPI:1609045939
Name:BEHNAZ SEPEHRIPOUR, DDS A PROFESSIONAL DENTAL CORPORATION
Entity type:Organization
Organization Name:BEHNAZ SEPEHRIPOUR, DDS A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BEHNAZ
Authorized Official - Middle Name:
Authorized Official - Last Name:SEPEHRIPOUR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-883-1234
Mailing Address - Street 1:8320 DESOTO AVE
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91304-1746
Mailing Address - Country:US
Mailing Address - Phone:818-883-1234
Mailing Address - Fax:818-883-9781
Practice Address - Street 1:8320 DESOTO AVE
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91304-2701
Practice Address - Country:US
Practice Address - Phone:818-883-1234
Practice Address - Fax:818-883-9781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA422241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9416401OtherDENTICAL