Provider Demographics
NPI: | 1710647151 |
---|---|
Name: | SURYAH HABIBI, DMD, INC |
Entity Type: | Organization |
Organization Name: | SURYAH HABIBI, DMD, INC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER DENTIST |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | SURYAH |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | HABIBI |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DMD, MPH |
Authorized Official - Phone: | 949-282-7428 |
Mailing Address - Street 1: | 17542 IRVINE BLVD STE D |
Mailing Address - Street 2: | |
Mailing Address - City: | TUSTIN |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 92780-3155 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 949-282-7428 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 17542 IRVINE BLVD STE D |
Practice Address - Street 2: | |
Practice Address - City: | TUSTIN |
Practice Address - State: | CA |
Practice Address - Zip Code: | 92780-3155 |
Practice Address - Country: | US |
Practice Address - Phone: | 949-282-7428 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2021-12-27 |
Last Update Date: | 2021-12-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | 100863 | Other | DENTIST |