Provider Demographics
NPI:1982740213
Name:MANSOURI, PARHAM
Entity Type:Individual
Prefix:
First Name:PARHAM
Middle Name:
Last Name:MANSOURI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12509 OXNARD ST
Mailing Address - Street 2:201
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-4440
Mailing Address - Country:US
Mailing Address - Phone:818-285-5757
Mailing Address - Fax:818-257-5760
Practice Address - Street 1:12509 OXNARD ST
Practice Address - Street 2:201
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-4467
Practice Address - Country:US
Practice Address - Phone:818-285-5757
Practice Address - Fax:818-257-5760
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA530851223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics