Provider Demographics
NPI:1306165964
Name:PICASSOSMILES
Entity type:Organization
Organization Name:PICASSOSMILES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NIMA
Authorized Official - Middle Name:E
Authorized Official - Last Name:SHAYESTEH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:310-663-6989
Mailing Address - Street 1:8863 ALCOTT ST APT 1
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-3368
Mailing Address - Country:US
Mailing Address - Phone:310-663-6989
Mailing Address - Fax:
Practice Address - Street 1:8863 ALCOTT ST APT 1
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-3368
Practice Address - Country:US
Practice Address - Phone:310-663-6989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-21
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24979122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty