Provider Demographics
NPI:1376620971
Name:MEHTAR, GHASSAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GHASSAN
Middle Name:
Last Name:MEHTAR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32281 CAMINO CAPISTRANO
Mailing Address - Street 2:101-C
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-3784
Mailing Address - Country:US
Mailing Address - Phone:949-661-9119
Mailing Address - Fax:949-661-9114
Practice Address - Street 1:32281 CAMINO CAPISTRANO
Practice Address - Street 2:101-C
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-3784
Practice Address - Country:US
Practice Address - Phone:949-661-9119
Practice Address - Fax:949-661-9114
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA442151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB44215-01OtherHEALTHY FAMILIES DELTA
CAG9 2741-01OtherDENTI CAL