Provider Demographics
NPI:1316080450
Name:SIAVASH, HESSAM S (DDS, MD)
Entity type:Individual
Prefix:
First Name:HESSAM
Middle Name:S
Last Name:SIAVASH
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 TELEGRAPH RD STE B
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-4185
Mailing Address - Country:US
Mailing Address - Phone:805-648-5121
Mailing Address - Fax:
Practice Address - Street 1:5200 TELEGRAPH RD STE B
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-4185
Practice Address - Country:US
Practice Address - Phone:805-648-5121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA597811223S0112X
CAA124710204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery