Healthcare Provider Details

I. General information

NPI: 1114101722
Provider Name (Legal Business Name): MOSTAFA MIRZABAGI DDS,MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23111 VENTURA BLVD 201
WOODLAND HILLS CA
91364-1103
US

IV. Provider business mailing address

23111 VENTURA BLVD 201
WOODLAND HILLS CA
91364-1103
US

V. Phone/Fax

Practice location:
  • Phone: 818-591-0945
  • Fax: 818-591-7570
Mailing address:
  • Phone: 818-591-0945
  • Fax: 818-591-7570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number37878
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: