Healthcare Provider Details

I. General information

NPI: 1033211099
Provider Name (Legal Business Name): MEHRAN MEHRABI MD, DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 09/05/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S ROOSEVELT DR STE A
BEAVER DAM WI
53916-2439
US

IV. Provider business mailing address

301 S ROOSEVELT DR STE A
BEAVER DAM WI
53916-2439
US

V. Phone/Fax

Practice location:
  • Phone: 920-356-9711
  • Fax: 920-356-9733
Mailing address:
  • Phone: 920-356-9711
  • Fax: 920-356-9733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6344-15
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number20002
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number52824-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: