Basic Information
| Provider Information | |||||||||
| NPI: | 1982369385 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GHAZALEH NOURI DENTAL CORP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MAGNOLIA MODERN DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3326 CLIPSTONE CT | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925035266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262357067 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3519 VAN BUREN BLVD STE 104 | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925030306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262357092 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2021 | ||||||||
| LastUpdateDate: | 11/03/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NOURI | ||||||||
| AuthorizedOfficialFirstName: | GHAZALEH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6262357067 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | 11/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.