Provider Demographics
NPI:1639314677
Name:POURADIB, MERSEDEH (DDS)
Entity Type:Individual
Prefix:
First Name:MERSEDEH
Middle Name:
Last Name:POURADIB
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 RUNNINGBROOK
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-1215
Mailing Address - Country:US
Mailing Address - Phone:714-573-2933
Mailing Address - Fax:714-573-2933
Practice Address - Street 1:2801 YULUPA AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-9115
Practice Address - Country:US
Practice Address - Phone:707-544-8338
Practice Address - Fax:707-544-8338
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-04
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45604122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist