Healthcare Provider Details

I. General information

NPI: 1487965828
Provider Name (Legal Business Name): MEHDI B MATIN D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2010
Last Update Date: 05/10/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9855 ERMA RD STE 100
SAN DIEGO CA
92131-1007
US

IV. Provider business mailing address

11921 CARMEL CREEK RD APT 310
SAN DIEGO CA
92130-2659
US

V. Phone/Fax

Practice location:
  • Phone: 858-536-2900
  • Fax: 858-271-0529
Mailing address:
  • Phone: 206-486-4946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDR 60288665
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDR60288665
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number12011690A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDDS60860
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: