Provider Demographics
NPI:1063782746
Name:BERAL, KOUROSH MICHAEL (DDS)
Entity type:Individual
Prefix:
First Name:KOUROSH
Middle Name:MICHAEL
Last Name:BERAL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 S HOOVER ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037-4045
Mailing Address - Country:US
Mailing Address - Phone:310-666-5453
Mailing Address - Fax:323-541-1494
Practice Address - Street 1:2204 PARNELL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-2005
Practice Address - Country:US
Practice Address - Phone:310-666-5453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46749122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist