Provider Demographics
NPI:1275743643
Name:MORAD, BRANDEN GHAZI (DDS)
Entity Type:Individual
Prefix:
First Name:BRANDEN
Middle Name:GHAZI
Last Name:MORAD
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:CALIFORNIA INSTITUTION FOR MEN
Mailing Address - Street 2:14901 CENTRAL AVE.
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710
Mailing Address - Country:US
Mailing Address - Phone:909-597-1821
Mailing Address - Fax:
Practice Address - Street 1:CALIFORNIA INSTITUTION FOR MEN
Practice Address - Street 2:14901 CENTRAL AVE.
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710
Practice Address - Country:US
Practice Address - Phone:909-597-1821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA371421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice