Basic Information
| Provider Information | |||||||||
| NPI: | 1548355571 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEYDARI | ||||||||
| FirstName: | MAHNAZ | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 FRUITVALE AVE | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946012322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105354000 | ||||||||
| FaxNumber: | 5105354128 | ||||||||
| Practice Location | |||||||||
| Address1: | 2920 SONOMA BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | VALLEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075582000 | ||||||||
| FaxNumber: | 7076443507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 53997 | CA | N | Dental Providers | Dentist | 122300000X | DDS53997 | CA | Y | Dental Providers | Dentist |
No ID Information.