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General NPI Number Information
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NPI Number | 1760861447
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Entity Type | Organization
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Legal Business Name | SHAHRESTANI SPARKS MARINA DENTISTRY, PC
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Dates
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Enumeration Date | 05/27/2015
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Last Update Date | 05/27/2015
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Provider Practice Location Address
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Address Line | 475 SPARKS BLVD SUITE 101
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City | SPARKS
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State | NV
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Zip | 89434-9002
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Country | US
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Telephone | 775-359-1565
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Fax | 775-359-1597
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Provider Business Mailing Address
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Address Line | 17000 RED HILL AVE
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City | IRVINE
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State | CA
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Zip | 92614-5626
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Country | US
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Telephone | 714-845-8890
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Fax | 949-474-1495
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Authorized Official
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Title or Position | CREDENTIALING ADMINISTRATOR
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Name | ALI SHAHRESTANI
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Credential | CYNTHIA CASTILLO
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Telephone | 714-845-8704
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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