Provider Demographics
NPI:1902161136
Name:MOONLIGHT DENTAL CENTER
Entity Type:Organization
Organization Name:MOONLIGHT DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS,PA
Authorized Official - Prefix:DR
Authorized Official - First Name:MAHIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RAHGOZAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,PA
Authorized Official - Phone:713-974-7252
Mailing Address - Street 1:2500 FONDREN RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-2308
Mailing Address - Country:US
Mailing Address - Phone:713-974-7252
Mailing Address - Fax:713-974-5822
Practice Address - Street 1:2500 FONDREN RD
Practice Address - Street 2:SUITE 205
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77063-2308
Practice Address - Country:US
Practice Address - Phone:713-974-7252
Practice Address - Fax:713-974-5822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX009577007Medicaid