MEDICARE: BERTRAM B. AMIRI DDS INC.

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	34586	CA

General Provider Information

NPI Number	:	1972917052
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BERTRAM B. AMIRI DDS INC.

Provider Business Mailing Address
First Line	:	3500 WHITTIER BLVD
Second Line	:	101
City	:	LOS ANGELES
State	:	CA
Zip	:	90023-1746
Country	:	US
Telephone Number	:	323-264-8834
Fax Number	:	323-264-0885

Provider Business Practice Location Address
First Line	:	3500 WHITTIER BLVD
Second Line	:	101
City	:	LOS ANGELES
State	:	CA
Zip	:	90023-1746
Country	:	US
Telephone Number	:	323-264-8834
Fax Number	:	323-264-0885

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BERTRAM AMIRI
Credential	:	DDS
Telephone Number	:	323-264-8834

Provider Enumeration Date	:	06/17/2014
Last Update Date	:	06/17/2014

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