Provider Demographics
NPI:1215694161
Name:HAMEDANI, MOHAMMUD REZA RAZI (DMD)
Entity type:Individual
Prefix:DR
First Name:MOHAMMUD REZA
Middle Name:RAZI
Last Name:HAMEDANI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10562 EASTBORNE AVE APT 1/2
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-6084
Mailing Address - Country:US
Mailing Address - Phone:310-746-7690
Mailing Address - Fax:
Practice Address - Street 1:14401 BURBANK BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-4824
Practice Address - Country:US
Practice Address - Phone:310-746-7690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-25
Last Update Date:2021-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1071361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice