Healthcare Provider Details

I. General information

NPI: 1760231989
Provider Name (Legal Business Name): HOUMAN MIZANI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2024
Last Update Date: 05/20/2024
Certification Date: 05/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16946 MARYGOLD AVE
FONTANA CA
92335-1724
US

IV. Provider business mailing address

137 ALPINE CT
ONTARIO CA
91762-3355
US

V. Phone/Fax

Practice location:
  • Phone: 909-355-0385
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS108762
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: