Provider Demographics
NPI:1629181854
Name:GHAFFARI, HOOSHANG (DENTIST)
Entity type:Individual
Prefix:
First Name:HOOSHANG
Middle Name:
Last Name:GHAFFARI
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 SURFVIEW DR.
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272
Mailing Address - Country:US
Mailing Address - Phone:818-599-2553
Mailing Address - Fax:310-459-9360
Practice Address - Street 1:333 SURFVIEW DR.
Practice Address - Street 2:
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272
Practice Address - Country:US
Practice Address - Phone:818-599-2553
Practice Address - Fax:310-459-9360
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30523122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB30523BMedicaid