Provider Demographics
NPI:1770789513
Name:GHOLIAN, SHERVIN (DMD, MMSC)
Entity type:Individual
Prefix:DR
First Name:SHERVIN
Middle Name:
Last Name:GHOLIAN
Suffix:
Gender:M
Credentials:DMD, MMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 CALIFORNIA BLVD
Mailing Address - Street 2:SUITE G
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2541
Mailing Address - Country:US
Mailing Address - Phone:805-543-7668
Mailing Address - Fax:805-543-7661
Practice Address - Street 1:620 CALIFORNIA BLVD
Practice Address - Street 2:SUITE G
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2541
Practice Address - Country:US
Practice Address - Phone:805-543-7668
Practice Address - Fax:805-543-7661
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA486031223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20-1089233OtherTAX IDENTIFICATION NUMBER