Provider Demographics
NPI:1790355063
Name:HOSSEINZADEH, NASRIN
Entity Type:Individual
Prefix:
First Name:NASRIN
Middle Name:
Last Name:HOSSEINZADEH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12121 WILSHIRE BLVD STE 1111
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1188
Mailing Address - Country:US
Mailing Address - Phone:310-820-9933
Mailing Address - Fax:
Practice Address - Street 1:2862 CANYON SPRINGS PKWY STE B
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-0928
Practice Address - Country:US
Practice Address - Phone:951-867-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106349122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA106349Medicaid