Provider Demographics
NPI:1144532672
Name:NAMAVAR, VIDA (DDS)
Entity type:Individual
Prefix:
First Name:VIDA
Middle Name:
Last Name:NAMAVAR
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 W SAN MARCOS BLVD
Mailing Address - Street 2:STE 103
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-1235
Mailing Address - Country:US
Mailing Address - Phone:619-850-9320
Mailing Address - Fax:
Practice Address - Street 1:670 W SAN MARCOS BLVD
Practice Address - Street 2:STE 103
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-1235
Practice Address - Country:US
Practice Address - Phone:619-850-9320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59394122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist