Healthcare Provider Details

I. General information

NPI: 1477177616
Provider Name (Legal Business Name): AMIR HOSSEINI DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2020
Last Update Date: 06/05/2020
Certification Date: 06/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 4TH ST STE C
PETALUMA CA
94952-3477
US

IV. Provider business mailing address

26 4TH ST STE C
PETALUMA CA
94952-3477
US

V. Phone/Fax

Practice location:
  • Phone: 707-787-5600
  • Fax: 707-787-5602
Mailing address:
  • Phone: 707-787-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: SEYED AMIR M HOSSEINI
Title or Position: CEO
Credential:
Phone: 707-787-5600