Provider Demographics
NPI:1245708551
Name:MEHRYAR, PAYMON PAUL
Entity type:Individual
Prefix:
First Name:PAYMON
Middle Name:PAUL
Last Name:MEHRYAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 E SILVERADO RANCH BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89183-3480
Mailing Address - Country:US
Mailing Address - Phone:702-425-6810
Mailing Address - Fax:
Practice Address - Street 1:45 E SILVERADO RANCH BLVD STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89183-3480
Practice Address - Country:US
Practice Address - Phone:702-425-6810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-05
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVS4-115C1223P0300X
TX346441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty