Provider Demographics
NPI:1679641146
Name:SOROUR, SELVANA (DMD)
Entity Type:Individual
Prefix:DR
First Name:SELVANA
Middle Name:
Last Name:SOROUR
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 1:7534 W 85TH ST
Mailing Address - Street 2:
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-8801
Mailing Address - Country:US
Mailing Address - Phone:310-795-3363
Mailing Address - Fax:
Practice Address - Street 1:12420 VENICE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-3840
Practice Address - Country:US
Practice Address - Phone:310-482-0025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54394122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist