Provider Demographics
NPI:1407196587
Name:MEHRDOKHT MEHRVARZI DENTAL CORP.
Entity Type:Organization
Organization Name:MEHRDOKHT MEHRVARZI DENTAL CORP.
Other - Org Name:SAN JUAN FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MEHRDOKHT
Authorized Official - Middle Name:
Authorized Official - Last Name:MEHRVARZI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-240-6888
Mailing Address - Street 1:31952 CAMINO CAPISTRANO STE C14&C16
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-3229
Mailing Address - Country:US
Mailing Address - Phone:949-240-6888
Mailing Address - Fax:949-240-7653
Practice Address - Street 1:31952 CAMINO CAPISTRANO STE C14&C16
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-3229
Practice Address - Country:US
Practice Address - Phone:949-240-6888
Practice Address - Fax:949-240-7653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-26
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39184261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental