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General NPI Number Information
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NPI Number | 1144210105
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Entity Type | Organization
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Legal Business Name | MAHALLATI DENTAL CORPORATION
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Dates
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Enumeration Date | 10/21/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3620 S BRISTOL ST SUITE #307
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City | SANTA ANA
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State | CA
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Zip | 92704-7300
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Country | US
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Telephone | 714-540-2836
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Fax | 714-540-4986
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Provider Business Mailing Address
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Address Line | 3620 S BRISTOL ST SUITE #307
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City | SANTA ANA
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State | CA
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Zip | 92704-7300
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Country | US
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Telephone | 714-540-2836
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Fax | 714-540-4986
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SHAHIN HASHEMBEIK MAHALLATI
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Credential | D.D.S.
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Telephone | 714-540-2836
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 43194
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License Number State | CA
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