Healthcare Provider Details

I. General information

NPI: 1730018276
Provider Name (Legal Business Name): SHAHLA GHODSI MOMENI DANAEI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14550 HAYNES ST STE 204
VAN NUYS CA
91411-4112
US

IV. Provider business mailing address

7018 ALABAMA AVE APT 203
CANOGA PARK CA
91303-3131
US

V. Phone/Fax

Practice location:
  • Phone: 818-650-6700
  • Fax:
Mailing address:
  • Phone: 747-216-8050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number112912
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: