MEDICARE: MARJAN MOHAMMADI D.D.S. INC.

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	1223G0001X	General Practice Dentistry	49940	CA

General Provider Information

NPI Number	:	1679005045
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARJAN MOHAMMADI D.D.S. INC.

Provider Business Mailing Address
First Line	:	550 N LARCHMONT BLVD STE 103
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90004-1318
Country	:	US
Telephone Number	:	323-962-6000
Fax Number	:	323-962-6002

Provider Business Practice Location Address
First Line	:	550 N LARCHMONT BLVD STE 103
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90004-1318
Country	:	US
Telephone Number	:	323-962-6000
Fax Number	:	323-962-6002

Authorized Official
Title or Position	:	OWNER
Name	:	MARJAN MOHAMMADI
Credential	:	D.D.S.
Telephone Number	:	323-962-6000

Provider Enumeration Date	:	04/03/2017
Last Update Date	:	04/03/2017

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