Provider Demographics
NPI:1790118024
Name:NAZEMI, AMIR REZA (RDH)
Entity Type:Individual
Prefix:MR
First Name:AMIR
Middle Name:REZA
Last Name:NAZEMI
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5515 CANOGA AVE APT 209
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-6628
Mailing Address - Country:US
Mailing Address - Phone:818-571-3639
Mailing Address - Fax:
Practice Address - Street 1:5515 CANOGA AVE, APT. 209
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367
Practice Address - Country:US
Practice Address - Phone:818-571-3639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-09
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26731124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist