Provider Demographics
NPI:1710647151
Name:SURYAH HABIBI, DMD, INC
Entity type:Organization
Organization Name:SURYAH HABIBI, DMD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SURYAH
Authorized Official - Middle Name:
Authorized Official - Last Name:HABIBI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MPH
Authorized Official - Phone:949-282-7428
Mailing Address - Street 1:17542 IRVINE BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3155
Mailing Address - Country:US
Mailing Address - Phone:949-282-7428
Mailing Address - Fax:
Practice Address - Street 1:17542 IRVINE BLVD STE D
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3155
Practice Address - Country:US
Practice Address - Phone:949-282-7428
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-27
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA100863OtherDENTIST