Provider Demographics
NPI:1457784050
Name:AHMADNIA, TARSA HATEFI (DDS)
Entity Type:Individual
Prefix:
First Name:TARSA
Middle Name:HATEFI
Last Name:AHMADNIA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22855 LAKE FOREST DR STE B
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-1647
Mailing Address - Country:US
Mailing Address - Phone:949-583-1558
Mailing Address - Fax:949-597-9768
Practice Address - Street 1:22855 LAKE FOREST DRIVE SUITE B
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630
Practice Address - Country:US
Practice Address - Phone:949-583-1558
Practice Address - Fax:949-597-9768
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35897122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist