Provider Demographics
NPI:1497033401
Name:NASSERI, ATHENA (DDS)
Entity Type:Individual
Prefix:
First Name:ATHENA
Middle Name:
Last Name:NASSERI
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 1:1150 E ANAHEIM ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-3663
Mailing Address - Country:US
Mailing Address - Phone:562-901-2700
Mailing Address - Fax:
Practice Address - Street 1:1150 E ANAHEIM ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-3663
Practice Address - Country:US
Practice Address - Phone:562-901-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10394122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO122300000XOtherNPI