Provider Demographics
NPI:1659309300
Name:H REZA A DENTAL CORPORATION
Entity Type:Organization
Organization Name:H REZA A DENTAL CORPORATION
Other - Org Name:H REZA SHAHMOHAMMADI A DENTAL CORPORATION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER.
Authorized Official - Prefix:MR
Authorized Official - First Name:HAMID
Authorized Official - Middle Name:REZA
Authorized Official - Last Name:REZA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:818-701-6667
Mailing Address - Street 1:8540 RESEDA BLVD. STE # 101
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324
Mailing Address - Country:US
Mailing Address - Phone:818-701-6667
Mailing Address - Fax:818-701-0418
Practice Address - Street 1:8540 RESEDA BLVD. STE # 101
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324
Practice Address - Country:US
Practice Address - Phone:818-701-6667
Practice Address - Fax:818-701-0418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA413071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB41307-02OtherDENTI-CAL