Provider Demographics
NPI:1275078107
Name:TAHIREE, MITRA (RDA)
Entity Type:Individual
Prefix:
First Name:MITRA
Middle Name:
Last Name:TAHIREE
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29264 ARIEL ST
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-2737
Mailing Address - Country:US
Mailing Address - Phone:951-834-5888
Mailing Address - Fax:
Practice Address - Street 1:29264 ARIEL ST
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-2737
Practice Address - Country:US
Practice Address - Phone:951-834-5888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-02
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA56326126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARDA56326Medicaid