Active NPI
Kooroush Mansourzadeh, D.D.S.
- Dentist
- Kent, WA
National Provider Identifier
1417309790
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- DE60655131
- Practice address
- 12906 SE Kent Kangley Rd
Kent, WA 98030-7940 - Phone
- (253) 361-3015
- NPI assigned
- Jul 11, 2016
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | DE60655131 | WA | Primary |
Addresses
Primary practice location
12906 SE Kent Kangley Rd
Kent, WA 98030-7940
Mailing address
12906 SE Kent Kangley Rd
Kent, WA 98030-7940
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| DE60655131 | WA | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1468195200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1468195200000",
"number": "1417309790",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "12906 SE KENT KANGLEY RD",
"city": "KENT",
"state": "WA",
"postal_code": "980307940"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "12906 SE KENT KANGLEY RD",
"city": "KENT",
"state": "WA",
"postal_code": "980307940",
"telephone_number": "253-361-3015"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MANSOURZADEH",
"first_name": "KOOROUSH",
"credential": "D.D.S.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2016-07-11",
"last_updated": "2016-07-11",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "WA",
"license": "DE60655131",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Kent, WA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 11, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.