Healthcare Provider Details

I. General information

NPI: 1083922827
Provider Name (Legal Business Name): MATTHEW NABI MOADEL DDS MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2010
Last Update Date: 03/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 N MARYLAND AVE #206
GLENDALE CA
91206-4261
US

IV. Provider business mailing address

3727 ROYAL WOODS DR
SHERMAN OAKS CA
91403-4217
US

V. Phone/Fax

Practice location:
  • Phone: 818-547-2804
  • Fax:
Mailing address:
  • Phone: 310-780-9959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number57793
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: