Provider Demographics
NPI:1083044184
Name:MOAZZENI, MINA (DDS)
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:MOAZZENI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 3RD PL
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98033-5556
Mailing Address - Country:US
Mailing Address - Phone:408-221-2009
Mailing Address - Fax:
Practice Address - Street 1:1505 3RD PL
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-5556
Practice Address - Country:US
Practice Address - Phone:408-221-2009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-26
Last Update Date:2015-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60496230122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist