Healthcare Provider Details

I. General information

NPI: 1174000574
Provider Name (Legal Business Name): PAUL MIRDAMADI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MR. PARHAM MIRDAMADI

II. Dates (important events)

Enumeration Date: 07/27/2018
Last Update Date: 12/31/2025
Certification Date: 12/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 ENCINITAS BLVD STE 118-120
ENCINITAS CA
92024-3775
US

IV. Provider business mailing address

511 ENCINITAS BLVD STE 118-120
ENCINITAS CA
92024-3775
US

V. Phone/Fax

Practice location:
  • Phone: 213-259-4867
  • Fax:
Mailing address:
  • Phone: 213-259-4867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD011746
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDDS104753
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: