Provider Demographics
NPI:1316186620
Name:YOUSEFI, SALLY (DDS)
Entity type:Individual
Prefix:DR
First Name:SALLY
Middle Name:
Last Name:YOUSEFI
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 1:107 N SWALL DR APT 203
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-3029
Mailing Address - Country:US
Mailing Address - Phone:818-515-4012
Mailing Address - Fax:
Practice Address - Street 1:500 E OLIVE AVE STE 430
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91501-2171
Practice Address - Country:US
Practice Address - Phone:818-515-4012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-10
Last Update Date:2009-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54912122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist