Provider Demographics
NPI:1275648909
Name:MOSTOFI, MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:MOSTOFI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:MOHAMMAD
Other - Middle Name:
Other - Last Name:MOSTOFI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:27791 LA PAZ RD
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-3919
Mailing Address - Country:US
Mailing Address - Phone:949-831-5511
Mailing Address - Fax:949-831-6624
Practice Address - Street 1:15 MAREBLU
Practice Address - Street 2:STE 360
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-3015
Practice Address - Country:US
Practice Address - Phone:949-831-5511
Practice Address - Fax:949-831-6624
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA526471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice