Provider Demographics
NPI:1457806838
Name:MESMARIAN, MOHAMMAD REZA (DDS)
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:REZA
Last Name:MESMARIAN
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 1:2603 VINEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-3370
Mailing Address - Country:US
Mailing Address - Phone:208-598-0383
Mailing Address - Fax:
Practice Address - Street 1:2603 VINEWOOD LN
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-3370
Practice Address - Country:US
Practice Address - Phone:719-564-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2029001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
COSTATE OF COLORADOOther202900