MEDICARE: MR. IKE HIMAYAT RAHIMI DMD

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	52455	CA

General Provider Information

NPI Number	:	1174525331
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. IKE HIMAYAT RAHIMI DMD

Provider Business Mailing Address
First Line	:	2808 MALLORD LN
Second Line	:
City	:	PLACERVILLE
State	:	CA
Zip	:	95667
Country	:	US
Telephone Number	:	530-622-0701
Fax Number	:	530-663-8491

Provider Business Practice Location Address
First Line	:	1045 MARSHALL WAY
Second Line	:
City	:	PLACERVILLE
State	:	CA
Zip	:	95667-5721
Country	:	US
Telephone Number	:	530-622-0701
Fax Number	:	530-622-7695

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

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	08/06/2020

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