Provider Demographics
NPI:1457428591
Name:MOKHTARI, EHSAN (DDS)
Entity Type:Individual
Prefix:MR
First Name:EHSAN
Middle Name:
Last Name:MOKHTARI
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 1:5825 RESEDA BLVD
Mailing Address - Street 2:#341
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-2024
Mailing Address - Country:US
Mailing Address - Phone:818-343-6890
Mailing Address - Fax:
Practice Address - Street 1:15243 VANOWEN ST
Practice Address - Street 2:#205
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3605
Practice Address - Country:US
Practice Address - Phone:818-780-7555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45149122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist