Provider Demographics
NPI:1346769452
Name:MEHRAN HAIDARI DMD PC
Entity Type:Organization
Organization Name:MEHRAN HAIDARI DMD PC
Other - Org Name:CLAYTON DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MEHRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAIDARI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:925-524-0444
Mailing Address - Street 1:5442 YGNACIO VALLEY RD STE 70
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94521-3827
Mailing Address - Country:US
Mailing Address - Phone:925-524-0444
Mailing Address - Fax:925-524-2472
Practice Address - Street 1:5442 YGNACIO VALLEY RD
Practice Address - Street 2:SUITE 70
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94521
Practice Address - Country:US
Practice Address - Phone:925-524-0444
Practice Address - Fax:925-524-2472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-11
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101324261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1598989741Medicaid