Provider Demographics
NPI:1629557996
Name:MEHDIPOUR, NAVID
Entity Type:Individual
Prefix:
First Name:NAVID
Middle Name:
Last Name:MEHDIPOUR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 DEL HOMBRE LN APT 447
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-2363
Mailing Address - Country:US
Mailing Address - Phone:213-905-1073
Mailing Address - Fax:
Practice Address - Street 1:5167 CLAYTON RD STE D
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94521-3163
Practice Address - Country:US
Practice Address - Phone:925-254-4777
Practice Address - Fax:925-800-7525
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1088741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC056312402Medicaid