Provider Demographics
NPI:1184882946
Name:KELISHADI-SAMANI, MARJAN (DDS)
Entity type:Individual
Prefix:
First Name:MARJAN
Middle Name:
Last Name:KELISHADI-SAMANI
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:PO BOX 3309
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES PENNINSULA
Mailing Address - State:CA
Mailing Address - Zip Code:90274
Mailing Address - Country:US
Mailing Address - Phone:310-830-3500
Mailing Address - Fax:310-830-7994
Practice Address - Street 1:23541 AVALON BLVD
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745
Practice Address - Country:US
Practice Address - Phone:310-830-3500
Practice Address - Fax:310-830-7994
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41930122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD41930Medicaid