Provider Demographics
NPI:1649472176
Name:GHASRI, PONEH (DDS)
Entity type:Individual
Prefix:
First Name:PONEH
Middle Name:
Last Name:GHASRI
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 1:6200 WILSHIRE BLVD
Mailing Address - Street 2:STE 1508
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5801
Mailing Address - Country:US
Mailing Address - Phone:323-938-6137
Mailing Address - Fax:323-938-1336
Practice Address - Street 1:6200 WILSHIRE BLVD
Practice Address - Street 2:STE 1508
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5801
Practice Address - Country:US
Practice Address - Phone:323-938-6137
Practice Address - Fax:323-938-1336
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50058122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist