Provider Demographics
NPI:1417021916
Name:BASTI, ALIREZA (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALIREZA
Middle Name:
Last Name:BASTI
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 1:27871 MEDICAL CENTER RD STE 180
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6463
Mailing Address - Country:US
Mailing Address - Phone:949-347-0780
Mailing Address - Fax:949-347-9549
Practice Address - Street 1:27871 MEDICAL CENTER RD STE 180
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6463
Practice Address - Country:US
Practice Address - Phone:949-347-0780
Practice Address - Fax:949-347-9549
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA498411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA49841OtherCA DENTAL LICENSE