Provider Demographics
NPI:1760114474
Name:YASERI, SHOKOUFEH (DDS)
Entity Type:Individual
Prefix:
First Name:SHOKOUFEH
Middle Name:
Last Name:YASERI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6447 REFLECTION DR APT 203
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-3124
Mailing Address - Country:US
Mailing Address - Phone:858-308-9373
Mailing Address - Fax:
Practice Address - Street 1:1350 E VISTA WAY STE 10
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-4037
Practice Address - Country:US
Practice Address - Phone:760-208-1173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107550122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist