Provider Demographics
NPI:1598802704
Name:KHOSHROZEH, MEHRDAD
Entity Type:Individual
Prefix:
First Name:MEHRDAD
Middle Name:
Last Name:KHOSHROZEH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4080 WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90023-2527
Mailing Address - Country:US
Mailing Address - Phone:323-582-4744
Mailing Address - Fax:323-582-3101
Practice Address - Street 1:4080 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90023-2527
Practice Address - Country:US
Practice Address - Phone:323-582-4744
Practice Address - Fax:323-582-3101
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43990122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG91571-01OtherDENTICAL OFFICE NUMBER
CAD43990OtherDENTICAL PROVIDER NUMBER
CAG91571-01OtherDENTICAL OFFICE NUMBER