=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447382965
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MANOUCHEHR MANOUCHEHR-POUR D.M.D. , M.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11635 SOUTH ST
-----------------------------------------------------
City | ARTESIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90701-6628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-924-4401
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18570 DYLAN ST
-----------------------------------------------------
City | NORTHRIDGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91326-1904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-491-0967
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 34999
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------