Provider Demographics
NPI:1275681652
Name:MAZLOMI, FARSHAD ALEX (DMD)
Entity Type:Individual
Prefix:
First Name:FARSHAD
Middle Name:ALEX
Last Name:MAZLOMI
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 1:617 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92880-1467
Mailing Address - Country:US
Mailing Address - Phone:951-273-3881
Mailing Address - Fax:951-738-1352
Practice Address - Street 1:617 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92880-1467
Practice Address - Country:US
Practice Address - Phone:951-273-3881
Practice Address - Fax:951-738-1352
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA445121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice