Provider Demographics
NPI:1790884260
Name:MEHRALI, MARK CYRUS (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:CYRUS
Last Name:MEHRALI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2438 N PONDEROSA DR STE C200
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-2374
Mailing Address - Country:US
Mailing Address - Phone:805-987-6991
Mailing Address - Fax:805-987-2919
Practice Address - Street 1:2438 N PONDEROSA DR STE C200
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-2374
Practice Address - Country:US
Practice Address - Phone:805-987-6991
Practice Address - Fax:805-987-2919
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA395481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice