MEDICARE: GOLIRZ GHIASSI DDS

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	36924	CA

General Provider Information

NPI Number	:	1497710248
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GOLIRZ GHIASSI DDS

Provider Business Mailing Address
First Line	:	712 D ST
Second Line	:	SUITE I
City	:	SAN RAFAEL
State	:	CA
Zip	:	94901-3709
Country	:	US
Telephone Number	:	415-454-1267
Fax Number	:	415-339-8336

Provider Business Practice Location Address
First Line	:	712 D ST
Second Line	:	SUITE I
City	:	SAN RAFAEL
State	:	CA
Zip	:	94901-3709
Country	:	US
Telephone Number	:	415-454-1267
Fax Number	:	415-339-8336

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

Provider Enumeration Date	:	04/17/2006
Last Update Date	:	05/20/2008

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