Provider Demographics
NPI:1205928496
Name:DAVID R MOGHADDAS DDS INC
Entity type:Organization
Organization Name:DAVID R MOGHADDAS DDS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:MOGHADDAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-641-8890
Mailing Address - Street 1:8930 S SEPULVEDA BLVD
Mailing Address - Street 2:SUITE #117
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045
Mailing Address - Country:US
Mailing Address - Phone:310-641-8890
Mailing Address - Fax:310-641-8859
Practice Address - Street 1:8930 S SEPULVEDA BLVD
Practice Address - Street 2:SUITE #117
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045
Practice Address - Country:US
Practice Address - Phone:310-641-8890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA40966122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty