Provider Demographics
NPI:1912253444
Name:MOSSAVI, EHSAN
Entity Type:Individual
Prefix:
First Name:EHSAN
Middle Name:
Last Name:MOSSAVI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11465 TUNNEL HILL WAY
Mailing Address - Street 2:
Mailing Address - City:GOLD RIVER
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7223
Mailing Address - Country:US
Mailing Address - Phone:916-239-5717
Mailing Address - Fax:
Practice Address - Street 1:11465 TUNNEL HILL WAY
Practice Address - Street 2:
Practice Address - City:GOLD RIVER
Practice Address - State:CA
Practice Address - Zip Code:95670-7223
Practice Address - Country:US
Practice Address - Phone:916-239-5717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-02
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61529122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist