Provider Demographics
NPI:1558746388
Name:SANJARI, KASRA (DDS)
Entity Type:Individual
Prefix:DR
First Name:KASRA
Middle Name:
Last Name:SANJARI
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 1:100 W COAST HWY UNIT R-203
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-5677
Mailing Address - Country:US
Mailing Address - Phone:949-942-1081
Mailing Address - Fax:
Practice Address - Street 1:100 W COAST HWY UNIT R-203
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-5677
Practice Address - Country:US
Practice Address - Phone:949-942-1081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-22
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15927122300000X
CADDS1022951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist