Provider Demographics
NPI:1477604551
Name:NOURI, IRAJ (DDS)
Entity Type:Individual
Prefix:DR
First Name:IRAJ
Middle Name:
Last Name:NOURI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1239 N AVALON BLVD
Mailing Address - Street 2:STE. A
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-2601
Mailing Address - Country:US
Mailing Address - Phone:310-518-2697
Mailing Address - Fax:310-518-6864
Practice Address - Street 1:1239 N AVALON BLVD
Practice Address - Street 2:STE. A
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-2601
Practice Address - Country:US
Practice Address - Phone:310-518-2697
Practice Address - Fax:310-518-6864
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA398561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB3985601OtherDENTI-CAL