Provider Demographics
NPI:1790200962
Name:AZAR MAHMOUDI,DDS,CORP
Entity Type:Organization
Organization Name:AZAR MAHMOUDI,DDS,CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AZAR
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHMOUDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-997-5957
Mailing Address - Street 1:2819 CROW CANYON RD STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-1656
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2819 CROW CANYON RD STE 104
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1656
Practice Address - Country:US
Practice Address - Phone:925-837-2225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-09
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental