Provider Demographics
NPI:1558638338
Name:MIRMOGHTADAEI, NIMA (DDS)
Entity Type:Individual
Prefix:DR
First Name:NIMA
Middle Name:
Last Name:MIRMOGHTADAEI
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 1:1025 N 63RD ST APT E39
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68505-2204
Mailing Address - Country:US
Mailing Address - Phone:213-948-7004
Mailing Address - Fax:
Practice Address - Street 1:1025 N 63RD ST APT E39
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68505-2204
Practice Address - Country:US
Practice Address - Phone:213-948-7004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60743122300000X
NE100122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist