Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | DL10896 | MA |
N | 1223P0300X | Periodontist | 00201945 | CO |
Y | 1223P0300X | Periodontist | 60303 | CA |
NPI | 1053630780 |
---|---|
Provider Name | Ardavan Fateh |
First Address | San Francisco, CA 94127-2600 |
Second Address | San Francisco, CA 94127-2600 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/05/2010 |
Last Update Date | 16/09/2015 |