Healthcare Provider Details

I. General information

NPI: 1700240793
Provider Name (Legal Business Name): HEYDAR SHAHROKH DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 04/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4277 W EL SEGUNDO BLVD
HAWTHORNE CA
90250-4548
US

IV. Provider business mailing address

4277 W EL SEGUNDO BLVD
HAWTHORNE CA
90250-4548
US

V. Phone/Fax

Practice location:
  • Phone: 310-970-0900
  • Fax: 310-970-0223
Mailing address:
  • Phone: 310-970-0900
  • Fax: 310-970-0223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number40014
License Number StateCA

VIII. Authorized Official

Name: DR. HEYDAR SHAHROKH
Title or Position: PRESIDENT
Credential: DDS
Phone: 310-963-1234