Provider Demographics
NPI:1689002925
Name:BASSERI, NOOSHIN
Entity Type:Individual
Prefix:
First Name:NOOSHIN
Middle Name:
Last Name:BASSERI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3140 MELENDY DR
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-3509
Mailing Address - Country:US
Mailing Address - Phone:650-802-8232
Mailing Address - Fax:
Practice Address - Street 1:3140 MELENDY DRIVE
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070
Practice Address - Country:US
Practice Address - Phone:650-802-8232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-24
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA462125K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125K00000XDental ProvidersAdvanced Practice Dental Therapist