Provider Demographics
NPI:1447382965
Name:MANOUCHEHR-POUR, MANOUCHEHR (DMD , MS)
Entity Type:Individual
Prefix:DR
First Name:MANOUCHEHR
Middle Name:
Last Name:MANOUCHEHR-POUR
Suffix:
Gender:M
Credentials:DMD , MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18570 DYLAN ST
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91326-1904
Mailing Address - Country:US
Mailing Address - Phone:818-491-0967
Mailing Address - Fax:
Practice Address - Street 1:11635 SOUTH ST
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:CA
Practice Address - Zip Code:90701-6628
Practice Address - Country:US
Practice Address - Phone:562-924-4401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA349991223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics