Provider Demographics
NPI:1114467560
Name:PESARAN, NIKA (DDS)
Entity Type:Individual
Prefix:
First Name:NIKA
Middle Name:
Last Name:PESARAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1870 VINE ST UNIT 102
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-1156
Mailing Address - Country:US
Mailing Address - Phone:720-938-5093
Mailing Address - Fax:
Practice Address - Street 1:759 DEXTER ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-5043
Practice Address - Country:US
Practice Address - Phone:720-938-5093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-06
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CODEN.00203472122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program