Provider Demographics
NPI:1386095677
Name:MADI, IMAN M (DMD)
Entity type:Individual
Prefix:MR
First Name:IMAN
Middle Name:M
Last Name:MADI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:MR
Other - First Name:SEYED
Other - Middle Name:I
Other - Last Name:MOHAMMADI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:26302 LA PAZ RD, SUITE 207
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691
Mailing Address - Country:US
Mailing Address - Phone:949-830-1322
Mailing Address - Fax:
Practice Address - Street 1:26302 LA PAZ RD, SUITE 207
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691
Practice Address - Country:US
Practice Address - Phone:415-476-1731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100125122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA100125OtherCA DENTAL BOARD