Provider Demographics
NPI:1124414867
Name:SOHEILIMOGHADAM, MEHRDAD
Entity Type:Individual
Prefix:
First Name:MEHRDAD
Middle Name:
Last Name:SOHEILIMOGHADAM
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 1:132 WILDER WAY
Mailing Address - Street 2:
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454-1532
Mailing Address - Country:US
Mailing Address - Phone:310-760-6042
Mailing Address - Fax:
Practice Address - Street 1:132 WILDER WAY
Practice Address - Street 2:
Practice Address - City:NORTH WALES
Practice Address - State:PA
Practice Address - Zip Code:19454-1532
Practice Address - Country:US
Practice Address - Phone:310-760-6042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401414790122300000X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist