Provider Demographics
NPI:1184994717
Name:POURRAHIMI, PEGAH (DDS)
Entity type:Individual
Prefix:DR
First Name:PEGAH
Middle Name:
Last Name:POURRAHIMI
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 1:555 MARIN ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-4236
Mailing Address - Country:US
Mailing Address - Phone:805-405-4692
Mailing Address - Fax:
Practice Address - Street 1:555 MARIN ST
Practice Address - Street 2:SUITE 150
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-4236
Practice Address - Country:US
Practice Address - Phone:805-405-4692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-12
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58614122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA46-2765180OtherTIN