Provider Demographics
NPI:1508819806
Name:MAZLOOM, MORTEZA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MORTEZA
Middle Name:
Last Name:MAZLOOM
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 1:1915 GRASS VALLEY HWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-2840
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1915 GRASS VALLEY HWY
Practice Address - Street 2:SUITE 200
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-2840
Practice Address - Country:US
Practice Address - Phone:530-885-1968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA495961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice