Provider Demographics
NPI:1417154642
Name:KEIKHANZADEH, KOUROSH (DDS, MDSC)
Entity Type:Individual
Prefix:DR
First Name:KOUROSH
Middle Name:
Last Name:KEIKHANZADEH
Suffix:
Gender:M
Credentials:DDS, MDSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16661 VENTURA BLVD
Mailing Address - Street 2:SUITE #609
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-1914
Mailing Address - Country:US
Mailing Address - Phone:818-344-3559
Mailing Address - Fax:
Practice Address - Street 1:16661 VENTURA BLVD
Practice Address - Street 2:SUITE #609
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-1914
Practice Address - Country:US
Practice Address - Phone:818-344-3559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA538061223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics