Provider Demographics
NPI:1588425169
Name:MASOUDIAN KHOUZANI, MOHAMMAD (DDS, MPH)
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:
Last Name:MASOUDIAN KHOUZANI
Suffix:
Gender:
Credentials:DDS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1619
Mailing Address - Street 2:
Mailing Address - City:GOLDENDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98620-1619
Mailing Address - Country:US
Mailing Address - Phone:419-322-0598
Mailing Address - Fax:
Practice Address - Street 1:310 S ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:GOLDENDALE
Practice Address - State:WA
Practice Address - Zip Code:98620-9201
Practice Address - Country:US
Practice Address - Phone:509-773-4022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-19
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40350122300000X, 1223X2210X
WADE614883631223X2210X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223X2210XDental ProvidersDentistOrofacial Pain