1093083602 NPI number — MEHRAN R. LARI, DDS, PLLC

Table of content: (NPI 1093083602)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093083602 NPI number — MEHRAN R. LARI, DDS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEHRAN R. LARI, DDS, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CREATIVE SMILES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093083602
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15631 N ORACLE RD
Provider Second Line Business Mailing Address:
SUITE 187
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85739-8691
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-825-8112
Provider Business Mailing Address Fax Number:
520-825-2242

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15631 N ORACLE RD
Provider Second Line Business Practice Location Address:
SUITE 187
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85739-8691
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-825-8112
Provider Business Practice Location Address Fax Number:
520-825-2242
Provider Enumeration Date:
12/09/2011

Additional Information

Authorized Official

Authorized Official Last Name:
RASTEGAR-LARI
Authorized Official First Name:
MEHRAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
520-820-1319

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  6100 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 144939 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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