Provider Demographics
NPI:1003097783
Name:SIMANIAN, MITRA ELISHA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MITRA
Middle Name:ELISHA
Last Name:SIMANIAN
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 1:1200 ROSECRANS AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-2470
Mailing Address - Country:US
Mailing Address - Phone:310-414-0620
Mailing Address - Fax:310-414-0689
Practice Address - Street 1:1200 ROSECRANS AVE STE 210
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-2470
Practice Address - Country:US
Practice Address - Phone:310-414-0620
Practice Address - Fax:310-414-0689
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-21
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43562122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist