Provider Demographics
NPI:1508197146
Name:POURAT, TANIA (DDS)
Entity type:Individual
Prefix:
First Name:TANIA
Middle Name:
Last Name:POURAT
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 1:12021 WILSHIRE BLVD
Mailing Address - Street 2:# 745
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025
Mailing Address - Country:US
Mailing Address - Phone:310-880-5643
Mailing Address - Fax:
Practice Address - Street 1:12021 WILSHIRE BLVD # 745
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1206
Practice Address - Country:US
Practice Address - Phone:310-880-5643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59087122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist