Healthcare Provider Details

I. General information

NPI: 1568710333
Provider Name (Legal Business Name): A SABBAGH-FARD DDS & P. MASTOUR DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5620 SAWTELLE BLVD
CULVER CITY CA
90230-5508
US

IV. Provider business mailing address

5620 SAWTELLE BLVD
CULVER CITY CA
90230-5508
US

V. Phone/Fax

Practice location:
  • Phone: 310-390-6212
  • Fax: 310-390-6215
Mailing address:
  • Phone: 310-390-6212
  • Fax: 310-390-6215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. PEDRAM E. MASTOUR
Title or Position: DENTIST
Credential: D.D.S
Phone: 310-390-6212