Provider Demographics
NPI:1699939702
Name:EBRAHIMI, MAZIYAR (DMD)
Entity type:Individual
Prefix:DR
First Name:MAZIYAR
Middle Name:
Last Name:EBRAHIMI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9735 WILSHIRE BLVD
Mailing Address - Street 2:426
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-2107
Mailing Address - Country:US
Mailing Address - Phone:310-248-3636
Mailing Address - Fax:
Practice Address - Street 1:9735 WILSHIRE BLVD
Practice Address - Street 2:426
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-2107
Practice Address - Country:US
Practice Address - Phone:310-248-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-17
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN167081223E0200X
CA532081223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics