Provider Demographics
NPI:1689794745
Name:KH NOURISHAD INC
Entity Type:Organization
Organization Name:KH NOURISHAD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KHASHAYAR
Authorized Official - Middle Name:
Authorized Official - Last Name:NOURISHAD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-609-0009
Mailing Address - Street 1:PO BOX 17227
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91416-7227
Mailing Address - Country:US
Mailing Address - Phone:818-609-0009
Mailing Address - Fax:818-609-1158
Practice Address - Street 1:17703 VANOWEN ST
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-5602
Practice Address - Country:US
Practice Address - Phone:818-609-0009
Practice Address - Fax:818-609-1158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38892122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7103950001Medicare NSC
CAB3889201Medicare ID - Type Unspecified