Healthcare Provider Details

I. General information

NPI: 1033625181
Provider Name (Legal Business Name): DR. SEYYEDHOSSEIN MOUSAVI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2017
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22030 SHERMAN WAY STE 219
CANOGA PARK CA
91303-1855
US

IV. Provider business mailing address

45377 PALMWOOD DR
INDIO CA
92201-5112
US

V. Phone/Fax

Practice location:
  • Phone: 424-644-1646
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number102218
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number102218
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: