Healthcare Provider Details

I. General information

NPI: 1649472176
Provider Name (Legal Business Name): PONEH GHASRI D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 WILSHIRE BLVD STE 1508
LOS ANGELES CA
90048-5801
US

IV. Provider business mailing address

6200 WILSHIRE BLVD STE 1508
LOS ANGELES CA
90048-5801
US

V. Phone/Fax

Practice location:
  • Phone: 323-938-6137
  • Fax: 323-938-1336
Mailing address:
  • Phone: 323-938-6137
  • Fax: 323-938-1336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number50058
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: