Provider Demographics
NPI:1538858295
Name:MOUSAVI, NEDA
Entity type:Individual
Prefix:
First Name:NEDA
Middle Name:
Last Name:MOUSAVI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 AVENIDA SAN PABLO
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672
Mailing Address - Country:US
Mailing Address - Phone:520-203-2261
Mailing Address - Fax:
Practice Address - Street 1:308 AVENIDA SAN PABLO
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672
Practice Address - Country:US
Practice Address - Phone:520-203-2261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110362122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program