Provider Demographics
NPI:1235434911
Name:KHAKNEGAR, MOHAMMAD (DDS)
Entity Type:Individual
Prefix:MR
First Name:MOHAMMAD
Middle Name:
Last Name:KHAKNEGAR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2455 COLORADO BLVD.
Mailing Address - Street 2:#16
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041
Mailing Address - Country:US
Mailing Address - Phone:323-255-9663
Mailing Address - Fax:
Practice Address - Street 1:2455 COLORADO BLVD.
Practice Address - Street 2:#16
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041
Practice Address - Country:US
Practice Address - Phone:323-255-9663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-11
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58982122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist