Provider Demographics
NPI:1063607547
Name:RAHMATTAN, BAHAREH
Entity type:Individual
Prefix:
First Name:BAHAREH
Middle Name:
Last Name:RAHMATTAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 PFEIFFER RANCH RD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95120-1625
Mailing Address - Country:US
Mailing Address - Phone:800-417-4444
Mailing Address - Fax:714-571-3560
Practice Address - Street 1:1240 FARMERS LN
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-6707
Practice Address - Country:US
Practice Address - Phone:707-542-5200
Practice Address - Fax:707-579-3207
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56209122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD56209Medicaid