Provider Demographics
NPI:1003430653
Name:HAJIAN, PEGA MOGHADAM
Entity Type:Individual
Prefix:
First Name:PEGA
Middle Name:MOGHADAM
Last Name:HAJIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22951 MARIANO ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-6133
Mailing Address - Country:US
Mailing Address - Phone:818-212-4242
Mailing Address - Fax:
Practice Address - Street 1:714 TIVERTON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-8361
Practice Address - Country:US
Practice Address - Phone:310-825-9789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-29
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0401417805122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program