Provider Demographics
NPI:1063022903
Name:TOURGOLI, RAENA
Entity Type:Individual
Prefix:
First Name:RAENA
Middle Name:
Last Name:TOURGOLI
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 1:26642 CORTINA DR
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-5429
Mailing Address - Country:US
Mailing Address - Phone:949-510-7221
Mailing Address - Fax:
Practice Address - Street 1:9907 WALKER ST
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:CA
Practice Address - Zip Code:90630-3827
Practice Address - Country:US
Practice Address - Phone:714-581-8585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1049451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice