MEDICARE: A MIRACLE SMILE BY DR. DEZHAM DENTAL GROUP

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	52801	CA

General Provider Information

NPI Number	:	1770775447
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A MIRACLE SMILE BY DR. DEZHAM DENTAL GROUP

Provider Business Mailing Address
First Line	:	2131 CAPITOL AVE STE 100
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95816-5755
Country	:	US
Telephone Number	:	916-441-3311
Fax Number	:	916-441-0630

Provider Business Practice Location Address
First Line	:	2131 CAPITOL AVE
Second Line	:	SUITE 100
City	:	SACRAMENTO
State	:	CA
Zip	:	95816-5755
Country	:	US
Telephone Number	:	916-441-3311
Fax Number	:	916-441-0630

Authorized Official
Title or Position	:	OWNER
Name	:	DR. HASSAN DEZHAM
Credential	:
Telephone Number	:	916-441-3311

Provider Enumeration Date	:	08/15/2007
Last Update Date	:	08/15/2007

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