Provider Demographics
NPI:1578178109
Name:MOSHREFI, LINDA
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:MOSHREFI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 CLUB VIS
Mailing Address - Street 2:
Mailing Address - City:DOVE CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:92679-3747
Mailing Address - Country:US
Mailing Address - Phone:949-526-1076
Mailing Address - Fax:
Practice Address - Street 1:22 CLUB VISTA
Practice Address - Street 2:
Practice Address - City:DOVE CANYON
Practice Address - State:CA
Practice Address - Zip Code:92679-3747
Practice Address - Country:US
Practice Address - Phone:949-526-1076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105472122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist