Provider Demographics
NPI:1043374630
Name:TAHMASEBI, KOUROSH
Entity Type:Individual
Prefix:
First Name:KOUROSH
Middle Name:
Last Name:TAHMASEBI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6280 JACKSON DR STE 2
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-3436
Mailing Address - Country:US
Mailing Address - Phone:619-667-3330
Mailing Address - Fax:619-667-3337
Practice Address - Street 1:6280 JACKSON DR STE 2
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92119-3436
Practice Address - Country:US
Practice Address - Phone:619-667-3330
Practice Address - Fax:619-667-3337
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0239160122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist