Provider Demographics
NPI:1740544303
Name:SADRE-NASSIRI, ALIREZA (DMD)
Entity type:Individual
Prefix:DR
First Name:ALIREZA
Middle Name:
Last Name:SADRE-NASSIRI
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:PO BOX 1950
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-1950
Mailing Address - Country:US
Mailing Address - Phone:707-263-8382
Mailing Address - Fax:
Practice Address - Street 1:925 BEVINS CT
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-9754
Practice Address - Country:US
Practice Address - Phone:707-263-8382
Practice Address - Fax:707-263-5326
Is Sole Proprietor?:No
Enumeration Date:2012-06-28
Last Update Date:2025-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056780122300000X, 1223P0221X, 1223G0001X, 1223P0221X
WA60737991122300000X
CA1095411223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1223G0001XMedicaid