Provider Demographics
NPI:1417489246
Name:GHASSEMLOU, MICHELE (DDS)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:GHASSEMLOU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23460 STRATHERN ST
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91304-4457
Mailing Address - Country:US
Mailing Address - Phone:818-480-1422
Mailing Address - Fax:
Practice Address - Street 1:7474 S CAMINO DE OESTE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85746-9308
Practice Address - Country:US
Practice Address - Phone:520-883-5040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGRADUATION MAY 2017122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist