Provider Demographics
NPI:1043205420
Name:MODJTAHEDI, BIJAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:BIJAN
Middle Name:
Last Name:MODJTAHEDI
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 1:18109 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-5647
Mailing Address - Country:US
Mailing Address - Phone:714-962-2432
Mailing Address - Fax:714-962-3752
Practice Address - Street 1:18109 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-5647
Practice Address - Country:US
Practice Address - Phone:714-962-2432
Practice Address - Fax:714-962-3752
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-13
Last Update Date:2007-07-08
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
CA35523122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist