Provider Demographics
NPI:1487965828
Name:MATIN, MEHDI B (DDS)
Entity type:Individual
Prefix:DR
First Name:MEHDI
Middle Name:B
Last Name:MATIN
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 1:11921 CARMEL CREEK RD APT 310
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2659
Mailing Address - Country:US
Mailing Address - Phone:206-486-4946
Mailing Address - Fax:
Practice Address - Street 1:9855 ERMA RD STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-1007
Practice Address - Country:US
Practice Address - Phone:858-536-2900
Practice Address - Fax:858-271-0529
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-30
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADR 602886651223S0112X, 1223S0112X
WADR60288665204E00000X
IN12011690A390200000X
CADDS60860204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty