1629317318 NPI number — MARK TAHERI DDS. INC

Table of content: (NPI 1629317318)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629317318 NPI number — MARK TAHERI DDS. INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARK TAHERI DDS. INC
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:
Provider Other Organization Name Type Code:
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:
1629317318
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25864 TOURNAMENT RD
Provider Second Line Business Mailing Address:
F
Provider Business Mailing Address City Name:
VALENCIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91355-2339
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-291-6500
Provider Business Mailing Address Fax Number:
661-209-3131

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25864 TOURNAMENT RD STE F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALENCIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-291-6500
Provider Business Practice Location Address Fax Number:
661-209-3131
Provider Enumeration Date:
01/31/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TAHERI
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST/OWNER
Authorized Official Telephone Number:
310-991-3911

Provider Taxonomy Codes

  • Taxonomy code: 305R00000X , with the licence number:  58659 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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