Provider Demographics
NPI:1538240247
Name:ETEMADI, KHASHAYAR
Entity type:Individual
Prefix:DR
First Name:KHASHAYAR
Middle Name:
Last Name:ETEMADI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6071 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2525
Mailing Address - Country:US
Mailing Address - Phone:951-680-1777
Mailing Address - Fax:951-681-0177
Practice Address - Street 1:6071 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2525
Practice Address - Country:US
Practice Address - Phone:951-680-1777
Practice Address - Fax:951-681-0177
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA404321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG91243-02Medicare ID - Type UnspecifiedDENTI CAL PROVIDER NUMBER