Provider Demographics
NPI:1275831208
Name:DASTOURY, KAMRAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KAMRAN
Middle Name:
Last Name:DASTOURY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44015 7TH ST E
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-4124
Mailing Address - Country:US
Mailing Address - Phone:661-466-8266
Mailing Address - Fax:
Practice Address - Street 1:2290 KIPLING ST UNIT 2
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80215-1546
Practice Address - Country:US
Practice Address - Phone:661-466-8266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-28
Last Update Date:2018-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101382204E00000X
CAA146736261QA1903X
CO000203543204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical