Provider Demographics
NPI:1326294125
Name:FARSHIDPOUR, MARY M (DMD)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:M
Last Name:FARSHIDPOUR
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:M
Other - Last Name:FARSHIDPOUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:26071 RAMJIT CT
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-5536
Mailing Address - Country:US
Mailing Address - Phone:949-683-7721
Mailing Address - Fax:
Practice Address - Street 1:26071 RAMJIT CT
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-5536
Practice Address - Country:US
Practice Address - Phone:949-683-7721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA574371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice