Provider Demographics
NPI:1366653164
Name:MEHRAN FAKHERI DMD A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:MEHRAN FAKHERI DMD A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MEHRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FAKHERI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:818-897-1234
Mailing Address - Street 1:9722 LAUREL CANYON BLVD
Mailing Address - Street 2:
Mailing Address - City:ARLETA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-4106
Mailing Address - Country:US
Mailing Address - Phone:818-897-1234
Mailing Address - Fax:
Practice Address - Street 1:9722 LAUREL CANYON BLVD
Practice Address - Street 2:
Practice Address - City:ARLETA
Practice Address - State:CA
Practice Address - Zip Code:91331-4106
Practice Address - Country:US
Practice Address - Phone:818-897-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54426122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty