Provider Demographics
NPI:1356844583
Name:SHAHRAM NOURI DENTAL CORP.
Entity Type:Organization
Organization Name:SHAHRAM NOURI DENTAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SHAHRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:NOURI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-885-5200
Mailing Address - Street 1:9318 RESEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-2926
Mailing Address - Country:US
Mailing Address - Phone:818-885-5200
Mailing Address - Fax:818-885-0087
Practice Address - Street 1:5216 LAUREL CANYON BLVD
Practice Address - Street 2:
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-2710
Practice Address - Country:US
Practice Address - Phone:818-769-1347
Practice Address - Fax:818-769-3563
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHAHRAM NOURI DENTAL CORP.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48974122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty