Healthcare Provider Details

I. General information

NPI: 1629848973
Provider Name (Legal Business Name): DR. LADAN ZIAIE MATIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2024
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1548 N PACIFIC AVE
GLENDALE CA
91202-1214
US

IV. Provider business mailing address

1548 N PACIFIC AVE
GLENDALE CA
91202-1214
US

V. Phone/Fax

Practice location:
  • Phone: 310-780-1385
  • Fax:
Mailing address:
  • Phone: 310-780-1385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number109801
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: