Provider Demographics
NPI:1902985492
Name:REZVAN, EHSAN (DDS, MS)
Entity Type:Individual
Prefix:
First Name:EHSAN
Middle Name:
Last Name:REZVAN
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7880 WREN AVE
Mailing Address - Street 2:BUILDING D SUITE 144
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-4943
Mailing Address - Country:US
Mailing Address - Phone:408-842-9045
Mailing Address - Fax:408-842-7057
Practice Address - Street 1:7880 WREN AVE
Practice Address - Street 2:BUILDING D SUITE 144
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-4943
Practice Address - Country:US
Practice Address - Phone:408-842-9045
Practice Address - Fax:408-842-7057
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA534791223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics