Provider Demographics
NPI:1093873945
Name:POURKHOMAMI, GOLBARG (DMD)
Entity Type:Individual
Prefix:DR
First Name:GOLBARG
Middle Name:
Last Name:POURKHOMAMI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10240 N 31ST AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051-9564
Mailing Address - Country:US
Mailing Address - Phone:602-944-7199
Mailing Address - Fax:602-944-7781
Practice Address - Street 1:10240 N 31ST AVE STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-9564
Practice Address - Country:US
Practice Address - Phone:602-944-7199
Practice Address - Fax:602-944-7781
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6008122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist