Provider Demographics
NPI:1073878435
Name:KHOSHROU, ASHKAN
Entity Type:Individual
Prefix:DR
First Name:ASHKAN
Middle Name:
Last Name:KHOSHROU
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 1:430 W ERIE STREET
Mailing Address - Street 2:STE 200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1921
Mailing Address - Country:US
Mailing Address - Phone:949-584-2451
Mailing Address - Fax:
Practice Address - Street 1:1632 E KATELLA AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-5095
Practice Address - Country:US
Practice Address - Phone:949-584-2451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA620301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice