Provider Demographics
NPI:1760629539
Name:MOAYEDGHYASY, SOUDABEH (DMD)
Entity Type:Individual
Prefix:DR
First Name:SOUDABEH
Middle Name:
Last Name:MOAYEDGHYASY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22855 LAKE FOREST DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-1656
Mailing Address - Country:US
Mailing Address - Phone:949-583-1558
Mailing Address - Fax:949-597-9768
Practice Address - Street 1:22855 LAKE FOREST DR
Practice Address - Street 2:SUITE B
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-1656
Practice Address - Country:US
Practice Address - Phone:949-583-1558
Practice Address - Fax:949-597-9768
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-15
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA378801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice