Provider Demographics
NPI:1992226104
Name:MELISSA KHURASANY A PROFESSIONAL CORP
Entity type:Organization
Organization Name:MELISSA KHURASANY A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:ESMAILZADEH KHURASANY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:949-614-3651
Mailing Address - Street 1:5059 STILLWATER WAY
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-2628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 W SAN JOSE AVE
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-5204
Practice Address - Country:US
Practice Address - Phone:909-480-1705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-28
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64760261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental