Provider Demographics
NPI:1114308442
Name:LOTFI, MAHYAR (DMD)
Entity Type:Individual
Prefix:
First Name:MAHYAR
Middle Name:
Last Name:LOTFI
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 1:941 HYLAND DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-2229
Mailing Address - Country:US
Mailing Address - Phone:858-342-4420
Mailing Address - Fax:
Practice Address - Street 1:1455 STATE ROAD 436 STE 101
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-6514
Practice Address - Country:US
Practice Address - Phone:407-708-9228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-11
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS100138122300000X
FLDN 21268122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist