1003299892 NPI number — ROYA MIRKHAN,DMD,MSD,INC.

Table of content: (NPI 1003299892)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003299892 NPI number — ROYA MIRKHAN,DMD,MSD,INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROYA MIRKHAN,DMD,MSD,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:
1003299892
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12395 EL CAMINO REAL
Provider Second Line Business Mailing Address:
SUITE NUMBER 314
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-337-6264
Provider Business Mailing Address Fax Number:
858-755-6260

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12395 EL CAMINO REAL
Provider Second Line Business Practice Location Address:
SUITE NUMBER 314
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92130-3082
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-337-6264
Provider Business Practice Location Address Fax Number:
858-755-6260
Provider Enumeration Date:
06/30/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MIRKHAN
Authorized Official First Name:
ROYA
Authorized Official Middle Name:
NAZILA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
858-337-6264

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  44743 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223P0300X , with the licence number: 44743 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1396866000 . This is a "DENTISTRY" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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