Provider Demographics
NPI:1548355571
Name:HEYDARI, MAHNAZ M (DDS)
Entity type:Individual
Prefix:MRS
First Name:MAHNAZ
Middle Name:M
Last Name:HEYDARI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 FRUITVALE AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-2322
Mailing Address - Country:US
Mailing Address - Phone:510-535-4000
Mailing Address - Fax:510-535-4128
Practice Address - Street 1:2920 SONOMA BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590
Practice Address - Country:US
Practice Address - Phone:707-558-2000
Practice Address - Fax:707-644-3507
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53997122300000X
CADDS53997122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist