Healthcare Provider Details

I. General information

NPI: 1750786349
Provider Name (Legal Business Name): MO TAHERI, D.M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2014
Last Update Date: 10/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 NEWPORT BLVD SUITE 300
COSTA MESA CA
92627-3786
US

IV. Provider business mailing address

1640 NEWPORT BLVD SUITE 300
COSTA MESA CA
92627-3786
US

V. Phone/Fax

Practice location:
  • Phone: 949-200-3150
  • Fax:
Mailing address:
  • Phone: 949-200-3150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number63463
License Number StateCA

VIII. Authorized Official

Name: DR. MOHAMMAD TAHERI
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 949-200-3150