Provider Demographics
NPI:1639956410
Name:NASRIEH, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:NASRIEH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:KHASHAYAR
Other - Middle Name:
Other - Last Name:NASRIEH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1328 S BUNDY DR APT 5
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1387
Mailing Address - Country:US
Mailing Address - Phone:310-699-7275
Mailing Address - Fax:
Practice Address - Street 1:235 E BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-3776
Practice Address - Country:US
Practice Address - Phone:323-597-1148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1093331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice