Provider Demographics
NPI:1639240856
Name:MIR, MOHSEN (DDS)
Entity Type:Individual
Prefix:
First Name:MOHSEN
Middle Name:
Last Name:MIR
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 1:903 E DEL MAR BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-3201
Mailing Address - Country:US
Mailing Address - Phone:626-792-6195
Mailing Address - Fax:626-792-8786
Practice Address - Street 1:903 E DEL MAR BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-3201
Practice Address - Country:US
Practice Address - Phone:626-792-6195
Practice Address - Fax:626-792-8786
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36396122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG91607-01OtherDENTI-CAL PROVIDER NUMBER
CAB36396-01OtherDENTICAL PROVIDR NUMBER