Provider Demographics
NPI:1649622945
Name:EBRAHIMI, WAISE OMID (DDS)
Entity type:Individual
Prefix:DR
First Name:WAISE
Middle Name:OMID
Last Name:EBRAHIMI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8851 OLIVER PL
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:CA
Mailing Address - Zip Code:94568-1380
Mailing Address - Country:US
Mailing Address - Phone:925-548-7869
Mailing Address - Fax:
Practice Address - Street 1:841 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-4704
Practice Address - Country:US
Practice Address - Phone:332-237-6453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100317122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist