Provider Demographics
NPI:1174074199
Name:MOGHADAM, SEAN
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:MOGHADAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S 903 ASHLAND AVE APT 513
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:305 W 12TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1267
Practice Address - Country:US
Practice Address - Phone:312-333-6320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-14
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRES.003881122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist