Provider Demographics
NPI:1437445103
Name:MISTRY, KIRAN (DDS)
Entity Type:Individual
Prefix:
First Name:KIRAN
Middle Name:
Last Name:MISTRY
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 1:420 S STATE COLLEGE BLVD
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-4119
Mailing Address - Country:US
Mailing Address - Phone:714-772-0770
Mailing Address - Fax:714-772-7054
Practice Address - Street 1:420 S STATE COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-4119
Practice Address - Country:US
Practice Address - Phone:714-772-0770
Practice Address - Fax:714-772-7054
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-21
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADR60225674122300000X
CA613511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist