Provider Demographics
NPI:1780946707
Name:MOVASSAGHI DENTAL COORPORATION
Entity type:Organization
Organization Name:MOVASSAGHI DENTAL COORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALIREZA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOVASSAGHI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:323-585-9200
Mailing Address - Street 1:7700 S ALAMEDA ST
Mailing Address - Street 2:
Mailing Address - City:WALNUT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-3745
Mailing Address - Country:US
Mailing Address - Phone:323-585-9200
Mailing Address - Fax:323-585-9408
Practice Address - Street 1:7700 S ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:WALNUT PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-3745
Practice Address - Country:US
Practice Address - Phone:323-585-9200
Practice Address - Fax:323-585-9408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39189385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA39189Medicaid