Provider Demographics
NPI:1790864882
Name:MORTEZAIEFARD, GOLSHAN (DMD)
Entity Type:Individual
Prefix:
First Name:GOLSHAN
Middle Name:
Last Name:MORTEZAIEFARD
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 1:22110 ROSCOE BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91304
Mailing Address - Country:US
Mailing Address - Phone:818-888-4004
Mailing Address - Fax:
Practice Address - Street 1:22110 ROSCOE BLVD
Practice Address - Street 2:STE 101
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91304
Practice Address - Country:US
Practice Address - Phone:818-888-4004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39049122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist