Healthcare Provider Details

I. General information

NPI: 1912970724
Provider Name (Legal Business Name): MANDANA MOZAYENI-AZAR D.D.S., M.S.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 01/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 COASTAL OAK
NEWPORT COAST CA
92657-1655
US

IV. Provider business mailing address

3189 LANDER RD
PEPPER PIKE OH
44124-5442
US

V. Phone/Fax

Practice location:
  • Phone: 216-299-5223
  • Fax:
Mailing address:
  • Phone: 330-633-7076
  • Fax: 216-378-8964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number49379
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number21664
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number49379
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: