Healthcare Provider Details

I. General information

NPI: 1659874568
Provider Name (Legal Business Name): IRENE NOSRATI, DDS, AND EREZ NOSRATI, DMD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2018
Last Update Date: 03/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 NAUTILUS ST
LA JOLLA CA
92037-6139
US

IV. Provider business mailing address

5175 PEARLMAN WAY
SAN DIEGO CA
92130-3715
US

V. Phone/Fax

Practice location:
  • Phone: 317-507-9033
  • Fax:
Mailing address:
  • Phone: 317-507-9033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number65156
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number100669
License Number StateCA

VIII. Authorized Official

Name: DR. IRENE NOSRATI
Title or Position: PRESIDENT
Credential: DDS
Phone: 317-507-9033