Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | 51335 | CA |
Y | 204E00000X | Oral & Maxillofacial Surgeon | A106484 | CA |
NPI | 1508180456 |
---|---|
Provider Name | Heshaam M. Fallah |
First Address | Oakland, CA 94611-5641 |
Second Address | Oakland, CA 94611-5641 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/03/2010 |
Last Update Date | 11/02/2022 |