Provider Demographics
NPI:1497823561
Name:MASSOUMI, SAFOURA (DDS PEDIATRIC DENTIS)
Entity Type:Individual
Prefix:
First Name:SAFOURA
Middle Name:
Last Name:MASSOUMI
Suffix:
Gender:F
Credentials:DDS PEDIATRIC DENTIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:397 E ST
Mailing Address - Street 2:STE #A
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910
Mailing Address - Country:US
Mailing Address - Phone:619-425-9930
Mailing Address - Fax:619-425-9887
Practice Address - Street 1:397 E ST
Practice Address - Street 2:STE #A
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910
Practice Address - Country:US
Practice Address - Phone:619-425-9930
Practice Address - Fax:619-425-9887
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA406771223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9226501Medicaid