Healthcare Provider Details

I. General information

NPI: 1972122778
Provider Name (Legal Business Name): MOJAN MIRNIA DDS, MSD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2020
Last Update Date: 08/08/2022
Certification Date: 08/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 W ONTARIO AVE STE 102
CORONA CA
92882-5274
US

IV. Provider business mailing address

11 CIPRIANI
IRVINE CA
92606-8873
US

V. Phone/Fax

Practice location:
  • Phone: 949-981-7445
  • Fax:
Mailing address:
  • Phone: 949-981-7445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number105945
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: