Provider Demographics
NPI:1316159486
Name:MEHTAR DENTAL CORPORATION
Entity type:Organization
Organization Name:MEHTAR DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GHASSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MEHTAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-661-9119
Mailing Address - Street 1:32281 CAMINO CAPISTRANO
Mailing Address - Street 2:C-101
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675
Mailing Address - Country:US
Mailing Address - Phone:949-661-9119
Mailing Address - Fax:949-661-9114
Practice Address - Street 1:32281 CAMINO CAPISTRANO
Practice Address - Street 2:C-101
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-3784
Practice Address - Country:US
Practice Address - Phone:949-661-9119
Practice Address - Fax:949-661-9114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA442151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB-44215-01OtherHEALTHY FAMILY
CAG-92741-01OtherDENTI-CAL
CA44215OtherDELTA DENTAL