MEDICARE: FAIRD PAKRAVAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	39862	CA

General Provider Information

NPI Number	:	1225170186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FAIRD PAKRAVAN

Provider Business Mailing Address
First Line	:	12121 WILSHIRE BLVD
Second Line	:	SUITE 1111
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-1123
Country	:	US
Telephone Number	:	310-820-9933
Fax Number	:	310-820-0408

Provider Business Practice Location Address
First Line	:	12121 WILSHIRE BLVD
Second Line	:	SUITE 1111
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-1123
Country	:	US
Telephone Number	:	310-820-9933
Fax Number	:	310-820-0408

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	04/04/2012

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Directions to “ FAIRD PAKRAVAN ” Practice Location

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