Provider Demographics
NPI:1225607559
Name:POUR MONAJEM ZADEH, SEPIDEH
Entity Type:Individual
Prefix:
First Name:SEPIDEH
Middle Name:
Last Name:POUR MONAJEM ZADEH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 ARMACOST AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1468
Mailing Address - Country:US
Mailing Address - Phone:213-357-6807
Mailing Address - Fax:
Practice Address - Street 1:1260 ARMACOST AVE APT 203
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1468
Practice Address - Country:US
Practice Address - Phone:213-357-6807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2022-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV74851223G0001X
CADDS1070511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice