Provider Demographics
NPI:1043863061
Name:AMIDI, MARIO (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:AMIDI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18411 HATTERAS ST UNIT 114
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-1985
Mailing Address - Country:US
Mailing Address - Phone:818-357-1158
Mailing Address - Fax:
Practice Address - Street 1:821 W ROSECRANS AVE STE A&B
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90222-3821
Practice Address - Country:US
Practice Address - Phone:312-274-4524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-18
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA104189122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program