MEDICARE: DR. MAHTAB SADRAMELI DMD, MAGD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	45003	CA

General Provider Information

NPI Number	:	1154451565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MAHTAB SADRAMELI DMD, MAGD

Provider Business Mailing Address
First Line	:	2095 CALIFORNIA ST APT 411
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94109-4306
Country	:	US
Telephone Number	:	415-775-7918
Fax Number	:

Provider Business Practice Location Address
First Line	:	2095 CALIFORNIA ST APT 411
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94109-4306
Country	:	US
Telephone Number	:	415-775-7918
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	07/15/2009

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