Provider Demographics
NPI:1225185861
Name:MOAYEDI, MINA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MINA
Middle Name:
Last Name:MOAYEDI
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 1:11026 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-3901
Mailing Address - Country:US
Mailing Address - Phone:310-558-2785
Mailing Address - Fax:310-558-2786
Practice Address - Street 1:11026 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-3901
Practice Address - Country:US
Practice Address - Phone:310-558-2785
Practice Address - Fax:310-558-2786
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA425751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB42575-01OtherDENTI-CAL PROVIDER NUMBER