Provider Demographics
NPI:1568182681
Name:POURESA, SEPEHR (DMD)
Entity Type:Individual
Prefix:
First Name:SEPEHR
Middle Name:
Last Name:POURESA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:SEP
Other - Middle Name:
Other - Last Name:POURESA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:400 BEALE ST APT 2505
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94105-4435
Mailing Address - Country:US
Mailing Address - Phone:415-806-4184
Mailing Address - Fax:
Practice Address - Street 1:450 SUTTER ST RM 808
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94108-3910
Practice Address - Country:US
Practice Address - Phone:415-513-5066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-30
Last Update Date:2022-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107800122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist