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General NPI Number Information
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NPI Number | 1841596673
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Entity Type | Individual
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Provider Name | DR. REZA MAHMOUDIANI
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Gender | Male
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Dates
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Enumeration Date | 01/26/2011
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Last Update Date | 01/26/2011
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Provider Practice Location Address
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Address Line | 925 WEST 34TH STREET USC SCHOOL OF DENTISTRY
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City | LA
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State | CA
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Zip | 90089
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Country | US
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Telephone | 310-467-3669
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 6203
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City | ALHAMBRA
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State | CA
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Zip | 91802-6203
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Country | US
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Telephone | 310-467-3669
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 45288
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License Number State | CA
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