Provider Demographics
NPI:1770775447
Name:A MIRACLE SMILE BY DR. DEZHAM DENTAL GROUP
Entity type:Organization
Organization Name:A MIRACLE SMILE BY DR. DEZHAM DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HASSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEZHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-441-3311
Mailing Address - Street 1:2131 CAPITOL AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-5755
Mailing Address - Country:US
Mailing Address - Phone:916-441-3311
Mailing Address - Fax:916-441-0630
Practice Address - Street 1:2131 CAPITOL AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5755
Practice Address - Country:US
Practice Address - Phone:916-441-3311
Practice Address - Fax:916-441-0630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52801122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty