Provider Demographics
NPI:1518975457
Name:AMIRMOAZZAMI, SOHEIL (DDS)
Entity Type:Individual
Prefix:DR
First Name:SOHEIL
Middle Name:
Last Name:AMIRMOAZZAMI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15840 VENTURA BLVD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2932
Mailing Address - Country:US
Mailing Address - Phone:818-386-1170
Mailing Address - Fax:818-386-0069
Practice Address - Street 1:15840 VENTURA BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2932
Practice Address - Country:US
Practice Address - Phone:818-386-1170
Practice Address - Fax:818-386-0069
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45082122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
B4508201OtherDENTI-CAL