Provider Demographics
NPI:1528039138
Name:MOSHIRI, SOHRAB (DDS PS)
Entity Type:Individual
Prefix:
First Name:SOHRAB
Middle Name:
Last Name:MOSHIRI
Suffix:
Gender:M
Credentials:DDS PS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23111 VENTURA BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-1103
Mailing Address - Country:US
Mailing Address - Phone:818-518-5020
Mailing Address - Fax:818-222-2588
Practice Address - Street 1:23111 VENTURA BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-1103
Practice Address - Country:US
Practice Address - Phone:818-518-5020
Practice Address - Fax:818-222-2588
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-31
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA57391223S0112X
AZ48811223S0112X
CA535221223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OTH000Medicare UPIN