Provider Demographics
NPI:1790528750
Name:POURSAYAH, ALIREZA (DMD)
Entity type:Individual
Prefix:
First Name:ALIREZA
Middle Name:
Last Name:POURSAYAH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 DAVIDSON RD APT 136
Mailing Address - Street 2:
Mailing Address - City:PISCATAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08854-8109
Mailing Address - Country:US
Mailing Address - Phone:862-621-7382
Mailing Address - Fax:
Practice Address - Street 1:238 E BETTERAVIA RD STE D
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-7889
Practice Address - Country:US
Practice Address - Phone:805-242-4881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1101741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice