Provider Demographics
NPI:1346798311
Name:HABIBI, SURYAH (DMD)
Entity Type:Individual
Prefix:
First Name:SURYAH
Middle Name:
Last Name:HABIBI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17542 IRVINE BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3155
Mailing Address - Country:US
Mailing Address - Phone:949-282-7428
Mailing Address - Fax:
Practice Address - Street 1:17542 IRVINE BLVD STE D
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3155
Practice Address - Country:US
Practice Address - Phone:949-282-7428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-19
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1008631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA100863OtherDENTIST