Provider Demographics
NPI:1134483258
Name:CHALAK, AMIR MOHAMMAD (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:AMIR
Middle Name:MOHAMMAD
Last Name:CHALAK
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 CHINA BASIN ST APT 223
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94158-2363
Mailing Address - Country:US
Mailing Address - Phone:650-302-7909
Mailing Address - Fax:
Practice Address - Street 1:1580 WINCHESTER BLVD STE 101
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-0519
Practice Address - Country:US
Practice Address - Phone:408-379-5360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-03
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61292122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist