Healthcare Provider Details

I. General information

NPI: 1508045394
Provider Name (Legal Business Name): MOHSEN ROSHANAEI D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2007
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1131 E MAIN ST # 110
TUSTIN CA
92780-4416
US

IV. Provider business mailing address

PO BOX 6063
IRVINE CA
92616-6063
US

V. Phone/Fax

Practice location:
  • Phone: 661-252-3522
  • Fax:
Mailing address:
  • Phone: 661-252-3533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number54196
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number54196
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: