Healthcare Provider Details

I. General information

NPI: 1891110219
Provider Name (Legal Business Name): BEHNAM B. BASERI, DDS. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2014
Last Update Date: 05/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 S BEVERLY DR 108
BEVERLY HILLS CA
90212-3851
US

IV. Provider business mailing address

269 S BEVERLY DR 108
BEVERLY HILLS CA
90212-3851
US

V. Phone/Fax

Practice location:
  • Phone: 424-222-9202
  • Fax:
Mailing address:
  • Phone: 424-222-9202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number62519
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number62519
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number62519
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number62519
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number62519
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number62519
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number62519
License Number StateCA
# 8
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number62519
License Number StateCA
# 9
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number62519
License Number StateCA
# 10
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number62519
License Number StateCA

VIII. Authorized Official

Name: DR. BEHNAM BERNARD BASERI
Title or Position: OWNER
Credential: DDS
Phone: 310-877-4767