Provider Demographics
NPI:1235917022
Name:MOHTASHIM, ADEENA
Entity Type:Individual
Prefix:
First Name:ADEENA
Middle Name:
Last Name:MOHTASHIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40890 MARTY TER
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-4459
Mailing Address - Country:US
Mailing Address - Phone:702-927-5194
Mailing Address - Fax:
Practice Address - Street 1:5890 STONERIDGE DR STE 108
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-5825
Practice Address - Country:US
Practice Address - Phone:702-927-5194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1092401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice