Healthcare Provider Details

I. General information

NPI: 1164525697
Provider Name (Legal Business Name): REZA KASIRI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6755 MIRA MESA BLVD SUITE 218
SAN DIEGO CA
92121
US

IV. Provider business mailing address

6755 MIRA MESA BLVD SUITE 218
SAN DIEGO CA
92121
US

V. Phone/Fax

Practice location:
  • Phone: 858-552-0052
  • Fax: 858-576-1990
Mailing address:
  • Phone: 858-552-0052
  • Fax: 858-576-1990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberB36309
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberB36309
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: