Provider Demographics
NPI:1649768615
Name:TASOOJI, NICOLE SARAH (DMD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SARAH
Last Name:TASOOJI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4619 KESTER AVE UNIT 5
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-2513
Mailing Address - Country:US
Mailing Address - Phone:858-349-7111
Mailing Address - Fax:
Practice Address - Street 1:10921 WILSHIRE BLVD STE 812
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-4003
Practice Address - Country:US
Practice Address - Phone:310-208-7727
Practice Address - Fax:310-208-8866
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-25
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103635122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist