Healthcare Provider Details

I. General information

NPI: 1568992279
Provider Name (Legal Business Name): JUSTIN NASSIRI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 08/19/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 W BALTIMORE ST
BALTIMORE MD
21201-1510
US

IV. Provider business mailing address

4579 W OAK PARK DR
FRESNO CA
93722-3248
US

V. Phone/Fax

Practice location:
  • Phone: 310-626-3631
  • Fax:
Mailing address:
  • Phone: 310-626-3631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number102517
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: