Healthcare Provider Details

I. General information

NPI: 1306061734
Provider Name (Legal Business Name): PLAZA DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 WILSHIRE BLVD STE 102
LOS ANGELES CA
90017-2829
US

IV. Provider business mailing address

800 WILSHIRE BLVD STE 102
LOS ANGELES CA
90017-2829
US

V. Phone/Fax

Practice location:
  • Phone: 213-626-6161
  • Fax: 213-626-6163
Mailing address:
  • Phone: 213-626-6161
  • Fax: 213-626-6163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MOJGAN RAMEZANI
Title or Position: DENTIST
Credential: DDS
Phone: 213-626-6161