Healthcare Provider Details

I. General information

NPI: 1114589652
Provider Name (Legal Business Name): EHSAN ASADIZARGHRI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2019
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 N ROXBURY DR STE 203
BEVERLY HILLS CA
90210-5017
US

IV. Provider business mailing address

436 N ROXBURY DR STE 203
BEVERLY HILLS CA
90210-5017
US

V. Phone/Fax

Practice location:
  • Phone: 949-205-0234
  • Fax:
Mailing address:
  • Phone: 949-205-8904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number004094
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: