Provider Demographics
NPI:1285981159
Name:REZA KHAZAEIZADEH DDS INC
Entity type:Organization
Organization Name:REZA KHAZAEIZADEH DDS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REZA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAZAEIZADEH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:559-747-5200
Mailing Address - Street 1:243 N FARMERSVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:FARMERSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93223-1570
Mailing Address - Country:US
Mailing Address - Phone:559-747-5200
Mailing Address - Fax:559-747-5203
Practice Address - Street 1:243 N FARMERSVILLE BLVD
Practice Address - Street 2:
Practice Address - City:FARMERSVILLE
Practice Address - State:CA
Practice Address - Zip Code:93223-1570
Practice Address - Country:US
Practice Address - Phone:559-747-5200
Practice Address - Fax:559-747-5203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA570201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty