Provider Demographics
NPI:1750641726
Name:ANSARI, SHOKOUH (DMD)
Entity Type:Individual
Prefix:
First Name:SHOKOUH
Middle Name:
Last Name:ANSARI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32122 PASEO ADELANTO STE 1B
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-3605
Mailing Address - Country:US
Mailing Address - Phone:949-493-6166
Mailing Address - Fax:949-493-8910
Practice Address - Street 1:32122 PASEO ADELANTO STE 1B
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-3605
Practice Address - Country:US
Practice Address - Phone:949-493-6166
Practice Address - Fax:949-493-8910
Is Sole Proprietor?:No
Enumeration Date:2012-05-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA377781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice