Provider Demographics
NPI:1861510745
Name:KHORSANDI, NAZLY (DDS)
Entity Type:Individual
Prefix:MRS
First Name:NAZLY
Middle Name:
Last Name:KHORSANDI
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 1:626 11TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90402
Mailing Address - Country:US
Mailing Address - Phone:310-435-8184
Mailing Address - Fax:310-899-5111
Practice Address - Street 1:16500 VENTURA BLVD.
Practice Address - Street 2:SUITE 150
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436
Practice Address - Country:US
Practice Address - Phone:818-907-1818
Practice Address - Fax:310-899-5111
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA402511223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice