Provider Demographics
NPI:1427735539
Name:HAYDARI, JAVAD
Entity type:Individual
Prefix:
First Name:JAVAD
Middle Name:
Last Name:HAYDARI
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 1:9350 THE RESORT PKWY UNIT 1513
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-9221
Mailing Address - Country:US
Mailing Address - Phone:720-412-8347
Mailing Address - Fax:
Practice Address - Street 1:17644 VALLEY BLVD STE 1
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:CA
Practice Address - Zip Code:92316-3908
Practice Address - Country:US
Practice Address - Phone:909-328-6787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-30
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1091711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice