Provider Demographics
NPI:1477834307
Name:NOSRATI, IRENE (DDS)
Entity Type:Individual
Prefix:DR
First Name:IRENE
Middle Name:
Last Name:NOSRATI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:IRENE
Other - Middle Name:
Other - Last Name:BERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:5175 PEARLMAN WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-3715
Mailing Address - Country:US
Mailing Address - Phone:317-507-9033
Mailing Address - Fax:
Practice Address - Street 1:342 RANDALL RD
Practice Address - Street 2:
Practice Address - City:SOUTH ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60177-2261
Practice Address - Country:US
Practice Address - Phone:317-507-9033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-06
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011618A1223G0001X
CA651561223G0001X
IL0190287741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice