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General NPI Number Information
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NPI Number | 1891136768
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Entity Type | Individual
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Provider Name | MAHDAD NASSIRI D.D.S
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Gender | Male
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Dates
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Enumeration Date | 07/08/2013
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Last Update Date | 09/16/2023
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Provider Practice Location Address
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Address Line | 1416 PROFESSIONAL DR STE 202
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City | PETALUMA
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State | CA
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Zip | 94954-5108
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Country | US
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Telephone | 707-769-1162
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Fax |
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Provider Business Mailing Address
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Address Line | 1416 PROFESSIONAL DR STE 202
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City | PETALUMA
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State | CA
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Zip | 94954-5108
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Country | US
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Telephone | 707-769-1162
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | DDS100289
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License Number State | CA
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