Provider Demographics
NPI:1043791890
Name:A MOLA DDS APC
Entity Type:Organization
Organization Name:A MOLA DDS APC
Other - Org Name:SELECT DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALIREZA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLA
Authorized Official - Suffix:
Authorized Official - Credentials:GENERAL DENTIST DDS
Authorized Official - Phone:510-590-7297
Mailing Address - Street 1:145 E 14TH ST # 100
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-1661
Mailing Address - Country:US
Mailing Address - Phone:510-587-9400
Mailing Address - Fax:
Practice Address - Street 1:1050 NORTHGATE DR STE 505
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-2542
Practice Address - Country:US
Practice Address - Phone:415-499-9300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALIREZA MOLA DDS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-28
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA622461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty