Provider Demographics
NPI:1851542294
Name:NASIRI-ANSARI, AMITISS
Entity Type:Individual
Prefix:
First Name:AMITISS
Middle Name:
Last Name:NASIRI-ANSARI
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 1:2781 W. MACARTHUR BLVD #N
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704
Mailing Address - Country:US
Mailing Address - Phone:714-556-7277
Mailing Address - Fax:
Practice Address - Street 1:2781 W. MACARTHUR BLVD #N
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704
Practice Address - Country:US
Practice Address - Phone:714-556-7277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-03
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55817122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist