Provider Demographics
NPI:1255918660
Name:REZA GHASEMI, DDS INC.
Entity type:Organization
Organization Name:REZA GHASEMI, DDS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:REZA
Authorized Official - Middle Name:
Authorized Official - Last Name:GHASEMI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:323-457-8787
Mailing Address - Street 1:9849 ATLANTIC AVE STE F
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-5200
Mailing Address - Country:US
Mailing Address - Phone:323-457-8787
Mailing Address - Fax:
Practice Address - Street 1:9849 ATLANTIC AVE STE F
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-5200
Practice Address - Country:US
Practice Address - Phone:323-457-8787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA103781OtherDENTIST