Provider Demographics
NPI:1043976582
Name:MAHDAVI, NICOLE (DDS)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:MAHDAVI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 W 42ND PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90062-1541
Mailing Address - Country:US
Mailing Address - Phone:909-477-0320
Mailing Address - Fax:
Practice Address - Street 1:1821 W 42ND PL
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90062-1541
Practice Address - Country:US
Practice Address - Phone:909-477-0320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS106961122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist