Provider Demographics
NPI:1033267422
Name:BEHESHTIAN, MORTEZA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MORTEZA
Middle Name:
Last Name:BEHESHTIAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6395 RESERVOIR DR
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-9634
Mailing Address - Country:US
Mailing Address - Phone:916-683-2000
Mailing Address - Fax:916-683-2003
Practice Address - Street 1:8170 LAGUNA BLVD
Practice Address - Street 2:#300
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-7901
Practice Address - Country:US
Practice Address - Phone:916-683-2000
Practice Address - Fax:916-683-2003
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA467471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice