Provider Demographics
NPI:1821206970
Name:MEHRNIA, KOUROSH (DDS)
Entity Type:Individual
Prefix:DR
First Name:KOUROSH
Middle Name:
Last Name:MEHRNIA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20101 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-2134
Mailing Address - Country:US
Mailing Address - Phone:718-479-2120
Mailing Address - Fax:718-479-2202
Practice Address - Street 1:20101 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423-2134
Practice Address - Country:US
Practice Address - Phone:718-479-2120
Practice Address - Fax:718-479-2202
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048121-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice