Healthcare Provider Details

I. General information

NPI: 1891345112
Provider Name (Legal Business Name): MICHAEL PEDRAM DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MICHAEL PEDRAM DDS, MD

II. Dates (important events)

Enumeration Date: 09/18/2019
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5363 BALBOA BLVD STE 233
ENCINO CA
91316-2824
US

IV. Provider business mailing address

1560 LOMA VISTA DR
BEVERLY HILLS CA
90210-1939
US

V. Phone/Fax

Practice location:
  • Phone: 818-788-4424
  • Fax:
Mailing address:
  • Phone: 310-612-4365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number104435
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: