Provider Demographics
NPI:1750894374
Name:M NOSRATI DENTAL CORPORATION
Entity type:Organization
Organization Name:M NOSRATI DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MAHIN
Authorized Official - Middle Name:
Authorized Official - Last Name:NOSRATI-JAHROMI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-330-2273
Mailing Address - Street 1:13677 FOOTHILL BLVD STE M
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-0214
Mailing Address - Country:US
Mailing Address - Phone:909-330-2273
Mailing Address - Fax:
Practice Address - Street 1:13677 FOOTHILL BLVD STE M
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-0214
Practice Address - Country:US
Practice Address - Phone:909-330-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-06
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53932261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental