Provider Demographics
NPI:1336309285
Name:SHAYESTEH, NIMA ELAZAR (DMD)
Entity Type:Individual
Prefix:DR
First Name:NIMA
Middle Name:ELAZAR
Last Name:SHAYESTEH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8863 ALCOTT ST APT 1
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-3368
Mailing Address - Country:US
Mailing Address - Phone:310-663-6989
Mailing Address - Fax:
Practice Address - Street 1:10842 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-3610
Practice Address - Country:US
Practice Address - Phone:424-361-5218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-13
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA570351223S0112X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentist
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty