Provider Demographics
NPI:1437761475
Name:PARSA, POUYA
Entity Type:Individual
Prefix:
First Name:POUYA
Middle Name:
Last Name:PARSA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12275 CARMEL VISTA RD UNIT 224
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2536
Mailing Address - Country:US
Mailing Address - Phone:858-280-6264
Mailing Address - Fax:
Practice Address - Street 1:12275 CARMEL VISTA RD UNIT 224
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2536
Practice Address - Country:US
Practice Address - Phone:858-280-6264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105529122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program