Provider Demographics
NPI:1174923338
Name:MOGHBEL, REZA (DDS)
Entity type:Individual
Prefix:
First Name:REZA
Middle Name:
Last Name:MOGHBEL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 S BENTLEY AVE
Mailing Address - Street 2:302
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-5772
Mailing Address - Country:US
Mailing Address - Phone:510-371-3038
Mailing Address - Fax:
Practice Address - Street 1:20401 AVALON BLVD
Practice Address - Street 2:#A
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-3226
Practice Address - Country:US
Practice Address - Phone:310-217-1507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-25
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30396122300000X
CA63805122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist