Healthcare Provider Details

I. General information

NPI: 1982806089
Provider Name (Legal Business Name): KOROUSH BASSIRI D.D.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 BRISTOL ST SUITE H
COSTA MESA CA
92626-7946
US

IV. Provider business mailing address

320 BRISTOL ST SUITE H
COSTA MESA CA
92626-7946
US

V. Phone/Fax

Practice location:
  • Phone: 714-546-7595
  • Fax: 714-546-7597
Mailing address:
  • Phone: 714-546-7595
  • Fax: 714-546-7597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number43754
License Number StateCA

VIII. Authorized Official

Name: DR. KOROUSH BASSIRI
Title or Position: CEO
Credential: DDS
Phone: 714-546-7595