Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 60095 | CA |
NPI | 1003106949 |
---|---|
Provider Name | Joey Pedram |
First Address | Simi Valley, CA 93065-3158 |
Second Address | Simi Valley, CA 93065-3158 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/04/2011 |
Last Update Date | 12/04/2011 |