Provider Demographics
NPI:1285841197
Name:MOGHARABI, MITRA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MITRA
Middle Name:
Last Name:MOGHARABI
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 1:16550 VENTURA BLVD
Mailing Address - Street 2:STE 206
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2004
Mailing Address - Country:US
Mailing Address - Phone:818-905-8109
Mailing Address - Fax:
Practice Address - Street 1:16550 VENTURA BLVD
Practice Address - Street 2:STE 206
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2004
Practice Address - Country:US
Practice Address - Phone:818-905-8109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA388831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice