Provider Demographics
NPI:1912447566
Name:AMITISS NASIRI ANSARI DDS, INC.
Entity Type:Organization
Organization Name:AMITISS NASIRI ANSARI DDS, INC.
Other - Org Name:SOUTH COAST FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DDS/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMITISS
Authorized Official - Middle Name:
Authorized Official - Last Name:NASIRI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-556-7277
Mailing Address - Street 1:2781 W MACARTHUR BLVD
Mailing Address - Street 2:SUITE N
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-8300
Mailing Address - Country:US
Mailing Address - Phone:714-556-7277
Mailing Address - Fax:714-556-2021
Practice Address - Street 1:2781 W MACARTHUR BLVD
Practice Address - Street 2:SUITE N
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-8300
Practice Address - Country:US
Practice Address - Phone:714-556-7277
Practice Address - Fax:714-556-2021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55817122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty