Provider Demographics
NPI:1891313524
Name:KHOSHNOODI, ALIREZA
Entity Type:Individual
Prefix:
First Name:ALIREZA
Middle Name:
Last Name:KHOSHNOODI
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 1:21050 VANOWEN ST APT 301
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91303-3085
Mailing Address - Country:US
Mailing Address - Phone:702-528-2864
Mailing Address - Fax:702-528-2864
Practice Address - Street 1:21050 VANOWEN ST APT 301
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-3085
Practice Address - Country:US
Practice Address - Phone:702-528-2864
Practice Address - Fax:702-528-2864
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-09
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1858746122300000X
CA1086501223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No122300000XDental ProvidersDentist