Provider Demographics
NPI:1679632574
Name:YOUSEFZADEH, MOJGAN G (DDS)
Entity Type:Individual
Prefix:DR
First Name:MOJGAN
Middle Name:G
Last Name:YOUSEFZADEH
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 1:4145 SHADOW LN APT 134
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-5251
Mailing Address - Country:US
Mailing Address - Phone:408-375-2337
Mailing Address - Fax:
Practice Address - Street 1:1240 FARMERS LN
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-6707
Practice Address - Country:US
Practice Address - Phone:707-542-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54838122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist