Provider Demographics
NPI:1013003235
Name:RADI, MOJTABA G (DDS)
Entity Type:Individual
Prefix:DR
First Name:MOJTABA
Middle Name:G
Last Name:RADI
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 1:309 NATOMA ST
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-2619
Mailing Address - Country:US
Mailing Address - Phone:530-400-2118
Mailing Address - Fax:
Practice Address - Street 1:309 NATOMA ST
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-2619
Practice Address - Country:US
Practice Address - Phone:916-985-3366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA430661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice