Provider Demographics
NPI:1508045394
Name:ROSHANAEI, MOHSEN (DDS)
Entity type:Individual
Prefix:DR
First Name:MOHSEN
Middle Name:
Last Name:ROSHANAEI
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:PO BOX 6063
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92616-6063
Mailing Address - Country:US
Mailing Address - Phone:661-252-3533
Mailing Address - Fax:
Practice Address - Street 1:1131 E MAIN ST # 110
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-4416
Practice Address - Country:US
Practice Address - Phone:661-252-3522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-29
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA541961223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty