Provider Demographics
NPI:1225920572
Name:MIRSAEIDI-FARAHANI, SAM (DMD)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:MIRSAEIDI-FARAHANI
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 1:4307 SHAMROCK WAY
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-4608
Mailing Address - Country:US
Mailing Address - Phone:510-910-4130
Mailing Address - Fax:
Practice Address - Street 1:2025 REDWOOD RD STE 3
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-3278
Practice Address - Country:US
Practice Address - Phone:707-255-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-18
Last Update Date:2025-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1117551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice