Provider Demographics
NPI:1841596673
Name:MAHMOUDIANI, REZA
Entity Type:Individual
Prefix:DR
First Name:REZA
Middle Name:
Last Name:MAHMOUDIANI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6203
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91802-6203
Mailing Address - Country:US
Mailing Address - Phone:310-467-3669
Mailing Address - Fax:
Practice Address - Street 1:925 WEST 34TH STREET
Practice Address - Street 2:USC SCHOOL OF DENTISTRY
Practice Address - City:LA
Practice Address - State:CA
Practice Address - Zip Code:90089
Practice Address - Country:US
Practice Address - Phone:310-467-3669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45288122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist