Provider Demographics
NPI:1336278654
Name:MOUSSAVI, MAHNAZ (DDS)
Entity Type:Individual
Prefix:DR
First Name:MAHNAZ
Middle Name:
Last Name:MOUSSAVI
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 1:25004 BLUE RAVINE RD STE 111
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-5283
Mailing Address - Country:US
Mailing Address - Phone:916-355-8400
Mailing Address - Fax:916-355-8460
Practice Address - Street 1:25004 BLUE RAVINE RD STE 111
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-5283
Practice Address - Country:US
Practice Address - Phone:916-355-8400
Practice Address - Fax:916-355-8460
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA399901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice