Provider Demographics
NPI:1194803650
Name:MASSOTH, IRVIN RICHARD (DDS, MSD)
Entity type:Individual
Prefix:DR
First Name:IRVIN
Middle Name:RICHARD
Last Name:MASSOTH
Suffix:
Gender:M
Credentials:DDS, MSD
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Mailing Address - Street 1:5567 RESEDA BLVD
Mailing Address - Street 2:#100
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-2674
Mailing Address - Country:US
Mailing Address - Phone:818-705-1274
Mailing Address - Fax:818-705-6782
Practice Address - Street 1:5567 RESEDA BLVD
Practice Address - Street 2:#100
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-2674
Practice Address - Country:US
Practice Address - Phone:818-705-1274
Practice Address - Fax:818-705-6782
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA289571223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA709866OtherUNITED CONCORDIA-TAX ID