Healthcare Provider Details

I. General information

NPI: 1083058986
Provider Name (Legal Business Name): DR. MAYSAM MAGID SALEHPOUR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2013
Last Update Date: 03/24/2021
Certification Date: 03/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5153 JACKSON DR
LA MESA CA
91942-9021
US

IV. Provider business mailing address

5153 JACKSON DR
LA MESA CA
91942-9021
US

V. Phone/Fax

Practice location:
  • Phone: 619-460-2280
  • Fax: 619-460-2285
Mailing address:
  • Phone: 949-280-3009
  • Fax: 619-460-2285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number61527
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number61527
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: