Provider Demographics
NPI:1306056544
Name:MAHYAR MAHBOUB DDS, A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MAHYAR MAHBOUB DDS, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAHYAR
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHBOUB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-653-6318
Mailing Address - Street 1:4902 IRVINE CENTER DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-3305
Mailing Address - Country:US
Mailing Address - Phone:949-653-6318
Mailing Address - Fax:949-653-6374
Practice Address - Street 1:4902 IRVINE CENTER DR
Practice Address - Street 2:SUITE 202
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-3305
Practice Address - Country:US
Practice Address - Phone:949-653-6318
Practice Address - Fax:949-653-6374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA455861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG-92967-01Medicaid