Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 50457 | CA |
Y | 213EG0000X | General Practice | 50457 | CA |
N | 1223S0112X | Oral and Maxillofacial Surgeon | 50457 | CA |
NPI | 1033205026 |
---|---|
Provider Name | Dr. Kourosh Dianatyazdi |
First Address | Palm Desert, CA 92211-0484 |
Second Address | Palm Desert, CA 92211-0484 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/10/2006 |
Last Update Date | 14/04/2016 |