Provider Demographics
NPI:1205448149
Name:REZAEI, MASIH (DDS)
Entity type:Individual
Prefix:DR
First Name:MASIH
Middle Name:
Last Name:REZAEI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:MASIH
Other - Middle Name:
Other - Last Name:REZAEI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:6 RANCHO LAGUNA DR
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-4732
Mailing Address - Country:US
Mailing Address - Phone:909-374-1678
Mailing Address - Fax:
Practice Address - Street 1:355 S LEMON AVE STE P
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789-2741
Practice Address - Country:US
Practice Address - Phone:909-598-9097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1050761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty