Healthcare Provider Details

I. General information

NPI: 1447043559
Provider Name (Legal Business Name): POOYAN NASIBI DENTAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2025
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 PACIFIC BLVD
HUNTINGTON PARK CA
90255-2534
US

IV. Provider business mailing address

5501 PACIFIC BLVD
HUNTINGTON PARK CA
90255-2534
US

V. Phone/Fax

Practice location:
  • Phone: 323-597-1135
  • Fax: 323-372-9295
Mailing address:
  • Phone: 323-597-1135
  • Fax: 323-372-9295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. POOYAN NASIBI
Title or Position: OWNER
Credential: DDS
Phone: 424-208-4055