Healthcare Provider Details

I. General information

NPI: 1972728335
Provider Name (Legal Business Name): FRED MONEMPOUR,DDS,PROF CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 N BEDFORD DR SUITE 416
BEVERLY HILLS CA
90210-4321
US

IV. Provider business mailing address

435 N BEDFORD DR SUITE 416
BEVERLY HILLS CA
90210-4321
US

V. Phone/Fax

Practice location:
  • Phone: 310-278-5993
  • Fax:
Mailing address:
  • Phone: 310-278-5993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number46299
License Number StateCA

VIII. Authorized Official

Name: MS. LYN ROSARIO
Title or Position: ADMINISTRATOR
Credential:
Phone: 310-278-5993