Provider Demographics
NPI:1265848014
Name:MAHMOUD MAGHSOUDLOU LLC
Entity Type:Organization
Organization Name:MAHMOUD MAGHSOUDLOU LLC
Other - Org Name:ARIA DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MANOLO
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-522-2220
Mailing Address - Street 1:1648 PLAZA WAY
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4325
Mailing Address - Country:US
Mailing Address - Phone:509-522-2220
Mailing Address - Fax:509-522-0171
Practice Address - Street 1:1648 PLAZA WAY
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4325
Practice Address - Country:US
Practice Address - Phone:509-522-2220
Practice Address - Fax:509-522-0171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000089711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty