Healthcare Provider Details

I. General information

NPI: 1902914021
Provider Name (Legal Business Name): KOUROS IZADI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 CENTER DR STE. 101
SAN MARCOS CA
92069-3536
US

IV. Provider business mailing address

2860 MICHELLE 2ND FLOOR
IRVINE CA
92606-1009
US

V. Phone/Fax

Practice location:
  • Phone: 760-746-2045
  • Fax: 760-746-2033
Mailing address:
  • Phone: 714-508-3600
  • Fax: 714-368-2092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number53519
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: