Provider Demographics
NPI:1457044323
Name:MOMENI MOGHADDAM, MONA
Entity type:Individual
Prefix:
First Name:MONA
Middle Name:
Last Name:MOMENI MOGHADDAM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1756 MIDTOWN CIR UNIT A
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-2156
Mailing Address - Country:US
Mailing Address - Phone:209-298-6901
Mailing Address - Fax:
Practice Address - Street 1:45 STUART ST APT 1201
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-4750
Practice Address - Country:US
Practice Address - Phone:209-298-6901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-29
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016024001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice