Provider Demographics
NPI:1962619692
Name:MAHMOUDIAN, MEHRAN RON (DDS)
Entity type:Individual
Prefix:
First Name:MEHRAN
Middle Name:RON
Last Name:MAHMOUDIAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:MEHRAN
Other - Middle Name:
Other - Last Name:MAHMOUDIAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:17 VIA FALERNO
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-1617
Mailing Address - Country:US
Mailing Address - Phone:949-830-1999
Mailing Address - Fax:
Practice Address - Street 1:24310 MOULTON PKWY STE C1
Practice Address - Street 2:
Practice Address - City:LAGUNA WOODS
Practice Address - State:CA
Practice Address - Zip Code:92637-3306
Practice Address - Country:US
Practice Address - Phone:949-859-3988
Practice Address - Fax:949-859-3578
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA519691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice