Provider Demographics
NPI:1093246795
Name:SADRI, SAID JALIL (DMD)
Entity Type:Individual
Prefix:
First Name:SAID JALIL
Middle Name:
Last Name:SADRI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:SEYED JALIL
Other - Middle Name:
Other - Last Name:SADRI GHISAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:5939 LA SALLE AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-3225
Mailing Address - Country:US
Mailing Address - Phone:510-292-1771
Mailing Address - Fax:
Practice Address - Street 1:5939 LA SALLE AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-3225
Practice Address - Country:US
Practice Address - Phone:510-292-1771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-23
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49985122300000X, 1223G0001X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD4603092OtherDRIVER LICENSE