Provider Demographics
NPI:1801994959
Name:MAHBOUB, MADJID (DDS)
Entity type:Individual
Prefix:DR
First Name:MADJID
Middle Name:
Last Name:MAHBOUB
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 1:4507 ARTESIA BLVD STE 106
Mailing Address - Street 2:
Mailing Address - City:LAWNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:90260-3725
Mailing Address - Country:US
Mailing Address - Phone:310-214-0305
Mailing Address - Fax:310-214-0237
Practice Address - Street 1:4507 ARTESIA BLVD STE 106
Practice Address - Street 2:
Practice Address - City:LAWNDALE
Practice Address - State:CA
Practice Address - Zip Code:90260-3725
Practice Address - Country:US
Practice Address - Phone:310-214-0305
Practice Address - Fax:310-214-0237
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA394451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB39445-01Medicaid