Provider Demographics
NPI:1750595195
Name:KHODAPANAH, ELMIRA (DDS)
Entity type:Individual
Prefix:
First Name:ELMIRA
Middle Name:
Last Name:KHODAPANAH
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 1:12079 WORLD TRADE DR UNIT 4
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-4393
Mailing Address - Country:US
Mailing Address - Phone:858-485-8855
Mailing Address - Fax:
Practice Address - Street 1:2333 CAMINO DEL RIO S STE 140
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3607
Practice Address - Country:US
Practice Address - Phone:619-574-1810
Practice Address - Fax:619-574-1326
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA439891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice