Provider Demographics
NPI:1023401734
Name:DADSERESHT, AFSANEH S
Entity Type:Individual
Prefix:
First Name:AFSANEH
Middle Name:S
Last Name:DADSERESHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 S ELM DR APT 203
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-1132
Mailing Address - Country:US
Mailing Address - Phone:323-568-9593
Mailing Address - Fax:
Practice Address - Street 1:1115 S ELM DR APT 203
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-1132
Practice Address - Country:US
Practice Address - Phone:323-568-9593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-05
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18833124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist