Healthcare Provider Details

I. General information

NPI: 1043536550
Provider Name (Legal Business Name): PEDRAM FAKHERI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2010
Last Update Date: 02/15/2022
Certification Date: 02/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1769 S BEDFORD ST
LOS ANGELES CA
90035-4320
US

IV. Provider business mailing address

1769 S BEDFORD ST
LOS ANGELES CA
90035-4320
US

V. Phone/Fax

Practice location:
  • Phone: 310-666-7830
  • Fax:
Mailing address:
  • Phone: 310-666-7830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number59170
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: