Provider Demographics
NPI:1447430624
Name:GHOZLAN DENTAL CORP.
Entity Type:Organization
Organization Name:GHOZLAN DENTAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:AYMAN
Authorized Official - Middle Name:MAHMOUD
Authorized Official - Last Name:GHOZLAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-337-1077
Mailing Address - Street 1:1745 W KETTLEMAN LN
Mailing Address - Street 2:SUITE B
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-9287
Mailing Address - Country:US
Mailing Address - Phone:209-367-0700
Mailing Address - Fax:209-367-0717
Practice Address - Street 1:1745 W KETTLEMAN LN
Practice Address - Street 2:SUITE B
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-9287
Practice Address - Country:US
Practice Address - Phone:209-367-0700
Practice Address - Fax:209-367-0717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46060261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental