Provider Demographics
NPI:1982369385
Name:GHAZALEH NOURI DENTAL CORP
Entity Type:Organization
Organization Name:GHAZALEH NOURI DENTAL CORP
Other - Org Name:MAGNOLIA MODERN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GHAZALEH
Authorized Official - Middle Name:
Authorized Official - Last Name:NOURI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-235-7067
Mailing Address - Street 1:3326 CLIPSTONE CT
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-5266
Mailing Address - Country:US
Mailing Address - Phone:626-235-7067
Mailing Address - Fax:
Practice Address - Street 1:3519 VAN BUREN BLVD STE 104
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-0306
Practice Address - Country:US
Practice Address - Phone:626-235-7092
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-01
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty