Basic Information
| Provider Information | |||||||||
| NPI: | 1871649152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KERMANI | ||||||||
| FirstName: | HEDI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS, MDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TAVAJOHI-KERMANI | ||||||||
| OtherFirstName: | HEDIEH | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DDS, MDS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2549 EASTBLUFF DR STE B | ||||||||
| Address2: | #415 | ||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926603500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9496405050 | ||||||||
| FaxNumber: | 9496405051 | ||||||||
| Practice Location | |||||||||
| Address1: | 14119 PIONEER BLVD | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906503925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629292383 | ||||||||
| FaxNumber: | 3232497565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 08/20/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | 43565 | CA | Y | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
ID Information
| ID | Type | State | Issuer | Description | D43565 | 05 | CA | MEDICAID |