Provider Demographics
NPI:1780190629
Name:ANSARI DENTAL CORPORATION, INC.
Entity Type:Organization
Organization Name:ANSARI DENTAL CORPORATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAHSA
Authorized Official - Middle Name:
Authorized Official - Last Name:JABERIANSARI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:925-828-0824
Mailing Address - Street 1:21310 SAN RAMON VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-4066
Mailing Address - Country:US
Mailing Address - Phone:925-828-0824
Mailing Address - Fax:925-828-3426
Practice Address - Street 1:21310 SAN RAMON VALLEY BLVD.
Practice Address - Street 2:2
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-4000
Practice Address - Country:US
Practice Address - Phone:925-828-0824
Practice Address - Fax:925-828-3426
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAHSA JABERIANSARI DDS INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-12-14
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59856261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental