Provider Demographics
NPI:1386932812
Name:KHAZAII-TABARI, SHEIDA
Entity type:Individual
Prefix:MISS
First Name:SHEIDA
Middle Name:
Last Name:KHAZAII-TABARI
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 1:3440 E BERKSHIRE CT UNIT B
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-7527
Mailing Address - Country:US
Mailing Address - Phone:714-264-3131
Mailing Address - Fax:
Practice Address - Street 1:3440 E BERKSHIRE CT UNIT B
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92869-7527
Practice Address - Country:US
Practice Address - Phone:714-264-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60452122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist