Provider Demographics
NPI:1548323231
Name:POURYAVARI, ROYA (DMD)
Entity type:Individual
Prefix:
First Name:ROYA
Middle Name:
Last Name:POURYAVARI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2428 VISTA HOGAR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-4034
Mailing Address - Country:US
Mailing Address - Phone:949-903-9898
Mailing Address - Fax:949-219-0990
Practice Address - Street 1:500 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4620
Practice Address - Country:US
Practice Address - Phone:714-973-9005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA491941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice