Provider Demographics
NPI:1437288594
Name:EBRAHIMIAN, MARK (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:EBRAHIMIAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 SOQUEL AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-1401
Mailing Address - Country:US
Mailing Address - Phone:831-458-3368
Mailing Address - Fax:
Practice Address - Street 1:2112 SOQUEL AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-1401
Practice Address - Country:US
Practice Address - Phone:831-458-3368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA301671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice