Healthcare Provider Details

I. General information

NPI: 1871034397
Provider Name (Legal Business Name): R K NASSIRI, DDS, MSD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2017
Last Update Date: 03/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3466 MT DIABLO BLVD SUITE C207
LAFAYETTE CA
94549-7106
US

IV. Provider business mailing address

3466 MT DIABLO BLVD SUITE C207
LAFAYETTE CA
94549-7106
US

V. Phone/Fax

Practice location:
  • Phone: 925-298-5281
  • Fax: 925-298-5419
Mailing address:
  • Phone: 925-298-5281
  • Fax: 925-298-5419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number53997
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number55427
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number54020
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number54020
License Number StateCA

VIII. Authorized Official

Name: DR. RAMTIN NASSIRI
Title or Position: PRESIDENT
Credential: D.D.S., M.S.D.
Phone: 925-298-5281