Healthcare Provider Details

I. General information

NPI: 1699325985
Provider Name (Legal Business Name): NIPUN MAHAJAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2019
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 N 12TH ST
PHOENIX AZ
85006-2837
US

IV. Provider business mailing address

6920 S CIMARRON RD # 100
LAS VEGAS NV
89113-2135
US

V. Phone/Fax

Practice location:
  • Phone: 602-521-5150
  • Fax:
Mailing address:
  • Phone: 415-792-9178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberD012458
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: