Provider Demographics
NPI:1073636445
Name:MOEZI, JACKSON REZA (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:REZA
Last Name:MOEZI
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 1:1350 BURTON DR
Mailing Address - Street 2:STE 230
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-3542
Mailing Address - Country:US
Mailing Address - Phone:707-446-7701
Mailing Address - Fax:707-446-1628
Practice Address - Street 1:3000 ALAMO DR
Practice Address - Street 2:SUITE 107
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-6350
Practice Address - Country:US
Practice Address - Phone:707-446-7701
Practice Address - Fax:707-446-1628
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37707122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist