Provider Demographics
NPI:1326879495
Name:DARVISHI, ABOLGHASEM
Entity type:Individual
Prefix:
First Name:ABOLGHASEM
Middle Name:
Last Name:DARVISHI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:347 AUBURN WAY APT 1
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95129-1647
Mailing Address - Country:US
Mailing Address - Phone:408-966-8897
Mailing Address - Fax:
Practice Address - Street 1:2410 DYER LN
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-5322
Practice Address - Country:US
Practice Address - Phone:510-505-9409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1104781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice