Provider Demographics
NPI:1659614014
Name:SHOUSHTARI MOGHADDAM, ELINAZ (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELINAZ
Middle Name:
Last Name:SHOUSHTARI MOGHADDAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13700 MARINA POINTE DR UNIT 901
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-9263
Mailing Address - Country:US
Mailing Address - Phone:917-623-0743
Mailing Address - Fax:
Practice Address - Street 1:13700 MARINA POINTE DR UNIT 901
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-9263
Practice Address - Country:US
Practice Address - Phone:917-623-0743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-03
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62009122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist