Provider Demographics
NPI:1861514879
Name:EVANS, MITRA ESLAMIYEH (DDS)
Entity type:Individual
Prefix:DR
First Name:MITRA
Middle Name:ESLAMIYEH
Last Name:EVANS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23326 HAWTHORNE BLVD #350
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505
Mailing Address - Country:US
Mailing Address - Phone:310-375-3939
Mailing Address - Fax:310-378-6364
Practice Address - Street 1:23326 HAWTHORNE BLVD #350
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505
Practice Address - Country:US
Practice Address - Phone:310-375-3939
Practice Address - Fax:310-378-6364
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC0344831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice