Provider Demographics
NPI:1295076768
Name:MAHMOODI, MONA
Entity type:Individual
Prefix:
First Name:MONA
Middle Name:
Last Name:MAHMOODI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 MISSION ROCK ST UNIT 602
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94158-2151
Mailing Address - Country:US
Mailing Address - Phone:310-993-5758
Mailing Address - Fax:
Practice Address - Street 1:555 MISSION ROCK ST UNIT 602
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94158-2151
Practice Address - Country:US
Practice Address - Phone:310-993-5758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-08
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62200122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist