Provider Demographics
NPI:1912190992
Name:MASSOUDIAN, GITI (DDS)
Entity Type:Individual
Prefix:
First Name:GITI
Middle Name:
Last Name:MASSOUDIAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 CHUCKWAGON RD
Mailing Address - Street 2:
Mailing Address - City:ROLLING HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90274-5277
Mailing Address - Country:US
Mailing Address - Phone:310-971-8653
Mailing Address - Fax:
Practice Address - Street 1:1411 W 8TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3803
Practice Address - Country:US
Practice Address - Phone:310-241-0688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-22
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40168122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist