Provider Demographics
NPI:1366968331
Name:HOSSEINI, GHAZALEH
Entity type:Individual
Prefix:
First Name:GHAZALEH
Middle Name:
Last Name:HOSSEINI
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 1:2227 GRANITE DR
Mailing Address - Street 2:
Mailing Address - City:ALAMO
Mailing Address - State:CA
Mailing Address - Zip Code:94507-1604
Mailing Address - Country:US
Mailing Address - Phone:510-709-9453
Mailing Address - Fax:
Practice Address - Street 1:678 N WILSON WAY
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-4272
Practice Address - Country:US
Practice Address - Phone:714-571-3389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101949122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist