Provider Demographics
NPI:1437206331
Name:MOHAGHEGH DAVANI, LIDA (DDS)
Entity Type:Individual
Prefix:DR
First Name:LIDA
Middle Name:
Last Name:MOHAGHEGH DAVANI
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 1:8540 S SEPULVEDA BLVD STE 815
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-3808
Mailing Address - Country:US
Mailing Address - Phone:310-410-9470
Mailing Address - Fax:
Practice Address - Street 1:8540 S SEPULVEDA BLVD STE 815
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3808
Practice Address - Country:US
Practice Address - Phone:310-410-9470
Practice Address - Fax:310-410-4405
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA499391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD49939OtherMEDICAL PROVIDER NUMBER