Provider Demographics
NPI:1760861447
Name:SHAHRESTANI SPARKS MARINA DENTISTRY, PC
Entity Type:Organization
Organization Name:SHAHRESTANI SPARKS MARINA DENTISTRY, PC
Other - Org Name:SPARKS MARINA DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAHRESTANI
Authorized Official - Suffix:
Authorized Official - Credentials:CYNTHIA CASTILLO
Authorized Official - Phone:714-845-8704
Mailing Address - Street 1:17000 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5626
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:949-474-1495
Practice Address - Street 1:475 SPARKS BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89434-9002
Practice Address - Country:US
Practice Address - Phone:775-359-1565
Practice Address - Fax:775-359-1597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-27
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty