Healthcare Provider Details

I. General information

NPI: 1821913625
Provider Name (Legal Business Name): MINA GOUDARZI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 STATHAM BLVD
OXNARD CA
93033
US

IV. Provider business mailing address

1040 FLYNN RD
CAMARILLO CA
93012-8705
US

V. Phone/Fax

Practice location:
  • Phone: 805-330-8682
  • Fax: 805-728-1433
Mailing address:
  • Phone: 805-673-3930
  • Fax: 805-659-3217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number113619
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: