Healthcare Provider Details

I. General information

NPI: 1457428591
Provider Name (Legal Business Name): EHSAN MOKHTARI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15243 VANOWEN ST #205
VAN NUYS CA
91405-3605
US

IV. Provider business mailing address

5825 RESEDA BLVD #341
TARZANA CA
91356-2024
US

V. Phone/Fax

Practice location:
  • Phone: 818-780-7555
  • Fax:
Mailing address:
  • Phone: 818-343-6890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number45149
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: