Provider Demographics
NPI:1891136768
Name:NASSIRI, MAHDAD (DDS)
Entity Type:Individual
Prefix:
First Name:MAHDAD
Middle Name:
Last Name:NASSIRI
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 1:1416 PROFESSIONAL DR STE 202
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-5108
Mailing Address - Country:US
Mailing Address - Phone:707-769-1162
Mailing Address - Fax:
Practice Address - Street 1:1416 PROFESSIONAL DR STE 202
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-5108
Practice Address - Country:US
Practice Address - Phone:707-769-1162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-08
Last Update Date:2023-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1002891223P0300X
ORD101531223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics