Healthcare Provider Details

I. General information

NPI: 1376755678
Provider Name (Legal Business Name): JOHN GEORGE MOUTSATSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4674 BARRANCA PARKWAY
IRVINE CA
92604-4731
US

IV. Provider business mailing address

4674 BARRANCA PARKWAY
IRVINE CA
92604-4731
US

V. Phone/Fax

Practice location:
  • Phone: 949-551-2532
  • Fax: 949-551-2443
Mailing address:
  • Phone: 949-551-2532
  • Fax: 949-551-2443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number24151
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: