Provider Demographics
NPI:1750640694
Name:KHEIRKHAHI-LOVE, ELLIE
Entity Type:Individual
Prefix:DR
First Name:ELLIE
Middle Name:
Last Name:KHEIRKHAHI-LOVE
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:ELLIE
Other - Middle Name:
Other - Last Name:KHEIRKHAHI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS,MSD
Mailing Address - Street 1:72780 COUNTRY CLUB DR STE 402
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-4149
Mailing Address - Country:US
Mailing Address - Phone:760-836-1809
Mailing Address - Fax:760-270-1941
Practice Address - Street 1:72780 COUNTRY CLUB DR STE 402
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4149
Practice Address - Country:US
Practice Address - Phone:760-836-1809
Practice Address - Fax:760-270-1941
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-13
Last Update Date:2012-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46081122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist