Provider Demographics
NPI:1134328230
Name:MASHKOURI, NIMA (DMD)
Entity Type:Individual
Prefix:DR
First Name:NIMA
Middle Name:
Last Name:MASHKOURI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5750 W CENTINELA AVE APT 211
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-8821
Mailing Address - Country:US
Mailing Address - Phone:310-663-1580
Mailing Address - Fax:
Practice Address - Street 1:1304 15TH ST STE 200
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1811
Practice Address - Country:US
Practice Address - Phone:310-458-8811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA527561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice