MEDICARE: OAKRIDGE DENTAL INC

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	302R00000X	Health Maintenance Organization	38560	CA
2	305R00000X	Preferred Provider Organization	38560	CA

General Provider Information

NPI Number	:	1982896072
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OAKRIDGE DENTAL INC

Provider Business Mailing Address
First Line	:	5450 THORNWOOD DR STE B
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95123-1222
Country	:	US
Telephone Number	:	408-360-0270
Fax Number	:	408-360-0275

Provider Business Practice Location Address
First Line	:	5450 THORNWOOD DR STE B
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95123-1222
Country	:	US
Telephone Number	:	408-360-0270
Fax Number	:	408-360-0275

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. STEPHEN AMIR MASHHOON
Credential	:	D.D.S.
Telephone Number	:	408-360-0270

Provider Enumeration Date	:	08/13/2007
Last Update Date	:	03/08/2016

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