Provider Demographics
NPI:1548782923
Name:MORI KHATIBZADEH DDS INC.
Entity Type:Organization
Organization Name:MORI KHATIBZADEH DDS INC.
Other - Org Name:BLUE MOUNTAIN DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MORTEZA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHATIBZAD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:858-617-9051
Mailing Address - Street 1:6171 MISSION GORGE RD STE 114
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-3409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6171 MISSION GORGE ROAD
Practice Address - Street 2:SUITE #114
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120
Practice Address - Country:US
Practice Address - Phone:858-617-9051
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-07
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55489261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental