Healthcare Provider Details

I. General information

NPI: 1114308442
Provider Name (Legal Business Name): MAHYAR LOTFI D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 01/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 STATE ROAD 436 STE 101
CASSELBERRY FL
32707-6514
US

IV. Provider business mailing address

941 HYLAND DR
SANTA ROSA CA
95404-2229
US

V. Phone/Fax

Practice location:
  • Phone: 407-708-9228
  • Fax:
Mailing address:
  • Phone: 858-342-4420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS100138
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN 21268
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: