Provider Demographics
NPI:1497077895
Name:BAGHERI, MOJI M (DMD)
Entity Type:Individual
Prefix:DR
First Name:MOJI
Middle Name:M
Last Name:BAGHERI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4924 BALBOA BLVD
Mailing Address - Street 2:SUITE 365
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-3402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4924 BALBOA BLVD
Practice Address - Street 2:SUITE 365
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-3402
Practice Address - Country:US
Practice Address - Phone:818-326-2525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-25
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA601281223E0200X, 1223G0001X
NY0549801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice