=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871839704
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NADER D. GHIASSI DDS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2012
-----------------------------------------------------
Last Update Date | 12/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27231 ORTEGA HWY STE A
-----------------------------------------------------
City | SAN JUAN CAPISTRANO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92675-6732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-487-0800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27231 ORTEGA HWY STE A
-----------------------------------------------------
City | SAN JUAN CAPISTRANO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92675-6732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-487-0800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. NADER D GHIASSI
-----------------------------------------------------
Credential | D.D.S
-----------------------------------------------------
Telephone | 949-487-0800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 49887
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------