Healthcare Provider Details

I. General information

NPI: 1386839538
Provider Name (Legal Business Name): NADEREH H EBRAHIMI DDS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 09/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 FRESNO ST SUITE 204
FRESNO CA
93706-3600
US

IV. Provider business mailing address

1945 N FINE AVE SUITE 116
FRESNO CA
93727-1528
US

V. Phone/Fax

Practice location:
  • Phone: 559-457-5700
  • Fax: 559-457-5790
Mailing address:
  • Phone: 559-457-5800
  • Fax: 559-457-5894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number56293
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number56293
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: