Provider Demographics
NPI:1295335404
Name:NOURBAKHSH, IDA (DDS)
Entity type:Individual
Prefix:DR
First Name:IDA
Middle Name:
Last Name:NOURBAKHSH
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 1:1947 E REDONDO AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-3119
Mailing Address - Country:US
Mailing Address - Phone:801-641-1537
Mailing Address - Fax:
Practice Address - Street 1:1947 E REDONDO AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-3119
Practice Address - Country:US
Practice Address - Phone:801-641-1537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11890735-8903122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist