Provider Demographics
NPI:1699826479
Name:KIANOURI, SHADROUZ (DDS, MAGD)
Entity Type:Individual
Prefix:DR
First Name:SHADROUZ
Middle Name:
Last Name:KIANOURI
Suffix:
Gender:M
Credentials:DDS, MAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SEE VEE LN
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514-8130
Mailing Address - Country:US
Mailing Address - Phone:760-873-3443
Mailing Address - Fax:760-503-0205
Practice Address - Street 1:250 N SEE VEE LN
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-8130
Practice Address - Country:US
Practice Address - Phone:760-873-3443
Practice Address - Fax:760-503-0205
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA511771223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATHP11576FMedicaid
CA1659433191OtherEMPLOYER NPI
CA1659433191OtherEMPLOYER NPI
CATHP11576FMedicaid