Provider Demographics
NPI:1073670774
Name:MORTAZAVI, JAHANARA (DDS)
Entity Type:Individual
Prefix:
First Name:JAHANARA
Middle Name:
Last Name:MORTAZAVI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 POLLARD RD
Mailing Address - Street 2:SUITE #3
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-1420
Mailing Address - Country:US
Mailing Address - Phone:408-379-8780
Mailing Address - Fax:408-378-1493
Practice Address - Street 1:812 POLLARD RD
Practice Address - Street 2:SUITE #3
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-1420
Practice Address - Country:US
Practice Address - Phone:408-379-8780
Practice Address - Fax:408-378-1493
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA442191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice