Provider Demographics
NPI:1194399758
Name:KOSARI, NILOUFAR (DDS)
Entity Type:Individual
Prefix:DR
First Name:NILOUFAR
Middle Name:
Last Name:KOSARI
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 1:4401 SEPULVEDA BLVD UNIT 203
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-3934
Mailing Address - Country:US
Mailing Address - Phone:424-288-1616
Mailing Address - Fax:
Practice Address - Street 1:4401 SEPULVEDA BLVD UNIT 203
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-3934
Practice Address - Country:US
Practice Address - Phone:424-288-1616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-18
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CADDS107563122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA92911948F31015Medicaid