Provider Demographics
NPI:1306574868
Name:KHOSRAVIBABADI, HYKAL R (DDS)
Entity type:Individual
Prefix:
First Name:HYKAL
Middle Name:R
Last Name:KHOSRAVIBABADI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1985 E GLENOAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-2930
Mailing Address - Country:US
Mailing Address - Phone:818-699-3884
Mailing Address - Fax:
Practice Address - Street 1:1508 N RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2064
Practice Address - Country:US
Practice Address - Phone:505-753-0544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD5656122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist