MEDICARE: DR. MOJI M BAGHERI D.M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	60128	CA
2	1223G0001X	General Practice Dentistry	054980	NY
3	1223G0001X	General Practice Dentistry	60128	CA

General Provider Information

NPI Number	:	1497077895
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MOJI M BAGHERI D.M.D

Provider Business Mailing Address
First Line	:	4924 BALBOA BLVD
Second Line	:	SUITE 365
City	:	ENCINO
State	:	CA
Zip	:	91316-3402
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4924 BALBOA BLVD
Second Line	:	SUITE 365
City	:	ENCINO
State	:	CA
Zip	:	91316-3402
Country	:	US
Telephone Number	:	818-326-2525
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/25/2010
Last Update Date	:	06/10/2014

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