Provider Demographics
NPI:1619536919
Name:KOUSHYAR, HAMED
Entity Type:Individual
Prefix:
First Name:HAMED
Middle Name:
Last Name:KOUSHYAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20600 VENTURA BLVD UNIT 2748
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-6686
Mailing Address - Country:US
Mailing Address - Phone:424-284-8460
Mailing Address - Fax:
Practice Address - Street 1:1210 W ADAMS BLVD APT 304
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-7704
Practice Address - Country:US
Practice Address - Phone:408-444-3089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103763122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist