Provider Demographics
NPI:1275089567
Name:TAHERI, NADIA E (DMD)
Entity Type:Individual
Prefix:
First Name:NADIA
Middle Name:E
Last Name:TAHERI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:NADIA
Other - Middle Name:
Other - Last Name:EJRAI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:42119 ARCHWOOD ST
Mailing Address - Street 2:
Mailing Address - City:WESTHILL
Mailing Address - State:CA
Mailing Address - Zip Code:91307
Mailing Address - Country:US
Mailing Address - Phone:785-979-8800
Mailing Address - Fax:
Practice Address - Street 1:12903 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-2923
Practice Address - Country:US
Practice Address - Phone:785-979-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-28
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100451223G0001X
CA1004851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10045OtherDENTAL LICENSE