Provider Demographics
NPI:1063137305
Name:POURNEJAD, AVA (DDS)
Entity type:Individual
Prefix:DR
First Name:AVA
Middle Name:
Last Name:POURNEJAD
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 1:402 CERVANTES CT
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92617-4118
Mailing Address - Country:US
Mailing Address - Phone:949-235-9914
Mailing Address - Fax:
Practice Address - Street 1:640 S GAFFEY ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3027
Practice Address - Country:US
Practice Address - Phone:310-548-1273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-10
Last Update Date:2024-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022034664122300000X
CA108094122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist