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General NPI Number Information
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NPI Number | 1447043559
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Entity Type | Organization
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Legal Business Name | POOYAN NASIBI DENTAL INC
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Dates
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Enumeration Date | 05/22/2025
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Last Update Date | 05/22/2025
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Provider Practice Location Address
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Address Line | 5501 PACIFIC BLVD
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City | HUNTINGTON PARK
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State | CA
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Zip | 90255-2534
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Country | US
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Telephone | 323-597-1135
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Fax | 323-372-9295
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Provider Business Mailing Address
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Address Line | 5501 PACIFIC BLVD
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City | HUNTINGTON PARK
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State | CA
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Zip | 90255-2534
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Country | US
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Telephone | 323-597-1135
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Fax | 323-372-9295
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Authorized Official
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Title or Position | OWNER
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Name | DR. POOYAN NASIBI
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Credential | DDS
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Telephone | 424-208-4055
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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