Healthcare Provider Details

I. General information

NPI: 1003299892
Provider Name (Legal Business Name): ROYA MIRKHAN,DMD,MSD,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 06/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12395 EL CAMINO REAL SUITE NUMBER 314
SAN DIEGO CA
92130-3082
US

IV. Provider business mailing address

12395 EL CAMINO REAL SUITE NUMBER 314
SAN DIEGO CA
92130
US

V. Phone/Fax

Practice location:
  • Phone: 858-337-6264
  • Fax: 858-755-6260
Mailing address:
  • Phone: 858-337-6264
  • Fax: 858-755-6260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number44743
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number44743
License Number StateCA

VIII. Authorized Official

Name: DR. ROYA NAZILA MIRKHAN
Title or Position: PRESIDENT
Credential: DMD,MSD
Phone: 858-337-6264