Provider Demographics
NPI:1558406520
Name:MOGHIMI, DAVID K (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:K
Last Name:MOGHIMI
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 1:2100 W BEVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-3902
Mailing Address - Country:US
Mailing Address - Phone:323-724-9536
Mailing Address - Fax:323-724-5608
Practice Address - Street 1:2100 W BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-3902
Practice Address - Country:US
Practice Address - Phone:323-724-9536
Practice Address - Fax:323-724-5608
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA343861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB34386-02Medicaid