Provider Demographics
NPI:1942475546
Name:MADDAHI, KOUROSH (DDS)
Entity Type:Individual
Prefix:DR
First Name:KOUROSH
Middle Name:
Last Name:MADDAHI
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 1:436 N ROXBURY DR STE 202
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-5017
Mailing Address - Country:US
Mailing Address - Phone:310-888-7797
Mailing Address - Fax:310-888-7759
Practice Address - Street 1:436 N ROXBURY DR STE 202
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-5017
Practice Address - Country:US
Practice Address - Phone:310-888-7797
Practice Address - Fax:310-888-7759
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA035427122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist