Provider Demographics
NPI:1508427626
Name:MOSTAGHNI, EHSAN
Entity Type:Individual
Prefix:
First Name:EHSAN
Middle Name:
Last Name:MOSTAGHNI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 VINE ST APT Y183
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68505-2875
Mailing Address - Country:US
Mailing Address - Phone:949-232-5112
Mailing Address - Fax:
Practice Address - Street 1:4000 E CAMPUS LOOP S DEPT OF
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68583-1530
Practice Address - Country:US
Practice Address - Phone:949-232-5112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-28
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7562122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist