Provider Demographics
NPI:1205651106
Name:REFOUA, SOHEIL
Entity type:Individual
Prefix:
First Name:SOHEIL
Middle Name:
Last Name:REFOUA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2118 MALCOLM AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6306
Mailing Address - Country:US
Mailing Address - Phone:310-746-7959
Mailing Address - Fax:
Practice Address - Street 1:11870 SANTA MONICA BLVD STE 212
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-2281
Practice Address - Country:US
Practice Address - Phone:310-207-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS110420122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist