Provider Demographics
NPI:1114101722
Name:MIRZABAGI, MOSTAFA (DDS,MS)
Entity Type:Individual
Prefix:DR
First Name:MOSTAFA
Middle Name:
Last Name:MIRZABAGI
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23111 VENTURA BLVD
Mailing Address - Street 2:201
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-1103
Mailing Address - Country:US
Mailing Address - Phone:818-591-0945
Mailing Address - Fax:818-591-7570
Practice Address - Street 1:23111 VENTURA BLVD
Practice Address - Street 2:201
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-1103
Practice Address - Country:US
Practice Address - Phone:818-591-0945
Practice Address - Fax:818-591-7570
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-19
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA378781223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB37878-01OtherMEDICAL