Provider Demographics
NPI:1720003668
Name:MANSOURIAN, PEZHMAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:PEZHMAN
Middle Name:
Last Name:MANSOURIAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4015 MISSION OAKS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-5156
Mailing Address - Country:US
Mailing Address - Phone:805-987-2701
Mailing Address - Fax:805-987-7092
Practice Address - Street 1:4015 MISSION OAKS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-5156
Practice Address - Country:US
Practice Address - Phone:805-987-2701
Practice Address - Fax:805-987-7092
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47522122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
421669499OtherFEDERAL TAX ID NUMBER