MEDICARE: MEHDIPOUR DMD PC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1164230165
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEHDIPOUR DMD PC

Provider Business Mailing Address
First Line	:	3709 ESPRESSO CT
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95403-8660
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1401 GUERNEVILLE RD STE 300
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95403-4174
Country	:	US
Telephone Number	:	707-800-8002
Fax Number	:	707-800-8004

Authorized Official
Title or Position	:	OWNER
Name	:	NAVID MEHDIPOUR
Credential	:
Telephone Number	:	213-905-1073

Provider Enumeration Date	:	12/21/2024
Last Update Date	:	12/23/2024

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