Provider Demographics
NPI:1689235871
Name:GHALAMBOR, MOJTABA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MOJTABA
Middle Name:
Last Name:GHALAMBOR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1328 PASEO ALAMOS
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-4239
Mailing Address - Country:US
Mailing Address - Phone:626-488-8515
Mailing Address - Fax:
Practice Address - Street 1:255 S GRAND AVE STE 204
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-3035
Practice Address - Country:US
Practice Address - Phone:213-620-5777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1038761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice