Provider Demographics
NPI:1740444942
Name:EZZATI, NAZANIN (DDS)
Entity type:Individual
Prefix:
First Name:NAZANIN
Middle Name:
Last Name:EZZATI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18740 VENTURA BLVD
Mailing Address - Street 2:#304
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3366
Mailing Address - Country:US
Mailing Address - Phone:818-881-9293
Mailing Address - Fax:
Practice Address - Street 1:18740 VENTURA BLVD
Practice Address - Street 2:#304
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3366
Practice Address - Country:US
Practice Address - Phone:818-881-9293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46790122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist