Provider Demographics
NPI:1205907417
Name:MADANI, ABOLGHASSEM (DDS)
Entity type:Individual
Prefix:DR
First Name:ABOLGHASSEM
Middle Name:
Last Name:MADANI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20932 BROOKHURST ST
Mailing Address - Street 2:STE 207
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-6638
Mailing Address - Country:US
Mailing Address - Phone:714-965-9870
Mailing Address - Fax:714-965-9870
Practice Address - Street 1:20932 BROOKHURST ST
Practice Address - Street 2:STE 207
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92646-6638
Practice Address - Country:US
Practice Address - Phone:714-965-9870
Practice Address - Fax:714-965-9870
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA253271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice