Provider Demographics
NPI:1730244476
Name:MAZI, FARHAD (DDS)
Entity type:Individual
Prefix:DR
First Name:FARHAD
Middle Name:
Last Name:MAZI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:FRANK
Other - Middle Name:
Other - Last Name:MAZI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS, APC
Mailing Address - Street 1:19190 US HIGHWAY 18
Mailing Address - Street 2:SUITE A
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2558
Mailing Address - Country:US
Mailing Address - Phone:760-242-7753
Mailing Address - Fax:760-946-1122
Practice Address - Street 1:19190 US HIGHWAY 18
Practice Address - Street 2:SUITE A
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2558
Practice Address - Country:US
Practice Address - Phone:760-242-7753
Practice Address - Fax:760-946-1122
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA488321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD48832Medicaid
CAG92354-(01,02,03)Medicaid