Provider Demographics
NPI:1164078242
Name:JAVAN, NIMA
Entity Type:Individual
Prefix:
First Name:NIMA
Middle Name:
Last Name:JAVAN
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 1:24802 ACROPOLIS DR
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-4608
Mailing Address - Country:US
Mailing Address - Phone:714-414-2271
Mailing Address - Fax:
Practice Address - Street 1:821 W ROSECRANS AVE STE A
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90222-3821
Practice Address - Country:US
Practice Address - Phone:312-274-4524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104408122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist