Provider Demographics
NPI:1093283855
Name:MORADISERESHT, MEHDI
Entity Type:Individual
Prefix:
First Name:MEHDI
Middle Name:
Last Name:MORADISERESHT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 538
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91408-0538
Mailing Address - Country:US
Mailing Address - Phone:310-985-2065
Mailing Address - Fax:
Practice Address - Street 1:19749 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-2623
Practice Address - Country:US
Practice Address - Phone:818-661-4680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-08
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS103148122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist