Provider Demographics
NPI:1457087579
Name:POUR, MACY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MACY
Middle Name:
Last Name:POUR
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 1:11767 W SUNSET BLVD APT 104
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-2991
Mailing Address - Country:US
Mailing Address - Phone:310-906-8972
Mailing Address - Fax:
Practice Address - Street 1:11767 W SUNSET BLVD APT 104
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-2991
Practice Address - Country:US
Practice Address - Phone:310-906-8972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107680122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist