Provider Demographics
NPI:1629133921
Name:POURHAMIDI, JALEH (DMD, MDSC)
Entity Type:Individual
Prefix:DR
First Name:JALEH
Middle Name:
Last Name:POURHAMIDI
Suffix:
Gender:F
Credentials:DMD, MDSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 SUNSET WAY
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014
Mailing Address - Country:US
Mailing Address - Phone:702-968-1652
Mailing Address - Fax:702-990-4435
Practice Address - Street 1:4 SUNSET WAY
Practice Address - Street 2:BUILDING C
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014
Practice Address - Country:US
Practice Address - Phone:702-968-1652
Practice Address - Fax:702-990-4435
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVLL0027031223X0400X
NVS3-88C1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100506335Medicaid