Basic Information
Provider Information
NPI: 1598336281
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KHORSAND
FirstName: HASHMAT
MiddleName: JOHN
NamePrefix: DR.
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3935 BELLEZA DR
Address2:  
City: CERES
State: CA
PostalCode: 953077170
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 2808 W MONTE VISTA AVE
Address2:  
City: TURLOCK
State: CA
PostalCode: 953808409
CountryCode: US
TelephoneNumber: 2096672879
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/05/2021
LastUpdateDate: 07/05/2021
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 07/05/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X106465CAY Dental ProvidersDentist 

No ID Information.


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