MEDICARE: DR. MITRA JAVIDAN MAZDYASNI 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	38303	CA

General Provider Information

NPI Number	:	1891834941
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MITRA JAVIDAN MAZDYASNI DMD

Provider Business Mailing Address
First Line	:	3335 LOWER RIDGE RD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92130-1816
Country	:	US
Telephone Number	:	858-442-9421
Fax Number	:

Provider Business Practice Location Address
First Line	:	9420 MIRA MESA BLVD STE G
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92126-4848
Country	:	US
Telephone Number	:	858-271-0600
Fax Number	:

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

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	05/13/2021

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