Provider Demographics
NPI:1003247651
Name:MOGHADDAS, DAVID R (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:R
Last Name:MOGHADDAS
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 1:89 S. SEPULVEDA BLVD.
Mailing Address - Street 2:SUITE 117
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-0000
Mailing Address - Country:US
Mailing Address - Phone:310-641-8890
Mailing Address - Fax:310-641-8859
Practice Address - Street 1:89 S. SEPULVEDA BLVD
Practice Address - Street 2:SUITE 117
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-0000
Practice Address - Country:US
Practice Address - Phone:310-641-8890
Practice Address - Fax:310-641-8859
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA40966122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty