Provider Demographics
NPI:1255665659
Name:AHDOOT, MAURICE RAFAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MAURICE
Middle Name:RAFAEL
Last Name:AHDOOT
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 1:12209 SANTA MONICA BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-2517
Mailing Address - Country:US
Mailing Address - Phone:310-820-5600
Mailing Address - Fax:
Practice Address - Street 1:12209 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-2517
Practice Address - Country:US
Practice Address - Phone:818-621-1330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-01
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58545122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist