Provider Demographics
NPI:1952678922
Name:POUYAN & KHANIDEH DENTAL CORPORATION
Entity Type:Organization
Organization Name:POUYAN & KHANIDEH DENTAL CORPORATION
Other - Org Name:ENCINO BRIGHT SMILES DENTAL GROUP, POUYAN & KHANIDEH DENTAL CORP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEHRA
Authorized Official - Middle Name:
Authorized Official - Last Name:POUYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-893-9710
Mailing Address - Street 1:15720 VENTURA BLVD STE 609
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-4733
Mailing Address - Country:US
Mailing Address - Phone:818-385-3500
Mailing Address - Fax:818-788-7303
Practice Address - Street 1:15720 VENTURA BLVD STE 609
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-4733
Practice Address - Country:US
Practice Address - Phone:818-385-3500
Practice Address - Fax:818-788-7303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-18
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA548251223G0001X
CA549441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty