Provider Demographics
NPI:1003103326
Name:MORIDNIA, MOHAMMAD (DDS)
Entity Type:Individual
Prefix:MR
First Name:MOHAMMAD
Middle Name:
Last Name:MORIDNIA
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 1:3603 S. FRONT STREET
Mailing Address - Street 2:SUITE # 107
Mailing Address - City:BROOKSHIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77423
Mailing Address - Country:US
Mailing Address - Phone:713-730-9294
Mailing Address - Fax:
Practice Address - Street 1:3603 S. FRONT STREET
Practice Address - Street 2:SUITE #107
Practice Address - City:BROOKSHIRE
Practice Address - State:TX
Practice Address - Zip Code:77423
Practice Address - Country:US
Practice Address - Phone:832-279-8368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27064122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX27064Medicaid