Provider Demographics
NPI:1881053700
Name:MANSOURIAN, KIMIA (RDH)
Entity type:Individual
Prefix:
First Name:KIMIA
Middle Name:
Last Name:MANSOURIAN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4327 GOLDEN CENTER DR
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-6287
Mailing Address - Country:US
Mailing Address - Phone:530-621-7700
Mailing Address - Fax:888-491-9601
Practice Address - Street 1:4327 GOLDEN CENTER DR
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-6287
Practice Address - Country:US
Practice Address - Phone:530-621-7700
Practice Address - Fax:888-491-9601
Is Sole Proprietor?:No
Enumeration Date:2016-02-19
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDH27348124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist