Provider Demographics
NPI:1932455631
Name:MITRA MASHREGHI DMD DENTAL CORPORATION
Entity Type:Organization
Organization Name:MITRA MASHREGHI DMD DENTAL CORPORATION
Other - Org Name:ONSITE DENTAL (DBA)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST / PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MITRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MASHREGHI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:818-980-1200
Mailing Address - Street 1:3575 CAHUENGA BLVD W STE 115
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90068-1340
Mailing Address - Country:US
Mailing Address - Phone:818-980-1200
Mailing Address - Fax:818-980-1233
Practice Address - Street 1:3575 CAHUENGA BLVD W STE 115
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90068-1340
Practice Address - Country:US
Practice Address - Phone:818-980-1200
Practice Address - Fax:818-980-1233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-31
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55376122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty