Healthcare Provider Details

I. General information

NPI: 1639215536
Provider Name (Legal Business Name): H. REZA SHAHMOHAMADI DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12509 OXNARD ST 201
NORTH HOLLYWOOD CA
91606
US

IV. Provider business mailing address

12509 OXNARD ST 201
NORTH HOLLYWOOD CA
91606
US

V. Phone/Fax

Practice location:
  • Phone: 818-285-5757
  • Fax: 818-285-5760
Mailing address:
  • Phone: 818-285-5757
  • Fax: 818-285-5760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: SHAHMOHAMMADI HAMID REZA
Title or Position: DENTIST (OWNER)
Credential:
Phone: 818-285-5757